Posted by Gary Schwitzer in Screening
The following is a guest post from Dr. Richard Hoffman, one of our medical editors on HealthNewsReview.org, and a professor of medicine at the University of New Mexico School of Medicine and staff physician in the New Mexico VA Health Care System.
I’m attending the annual meeting of the American Urological Association. Late yesterday, the U.S. Preventive Services Task Force issued its final D recommendation against prostate cancer screening. Predictably the AUA leadership is up in arms, promptly releasing a statement expressing outrage at this recommendation. Earlier yesterday, before the final recommendation was released, the AUA held a Town Hall meeting on PSA testing. Dr. Timothy Wilt, a Task Force member, reviewed the summary data for screening benefits and harms and clearly articulated the reasoning behind the draft D rating (issued last October)—moderate certainty that there is no net benefit or that harms outweigh benefits.* However, another speaker, an expert in decision making, pointed out that evidence is often in the eye of the beholder. Indeed, Dr. Ruth Etzioni, a biostatistician with the Fred Hutchinson Cancer Center, presented modeling results based on the European screening trial and epidemiological data suggesting that very long-term prostate-cancer mortality benefits could be substantial. Given that screening is often started at age 50—when life expectancy could exceed 30 years–even the most recent 11-year European follow-up data might be insufficient to gauge the ultimate benefit.
However, the effect of the Task Force recommendation on practice is uncertain. Recent population-based survey results suggested that the 2008 Task Force recommendation against screening men over age 75 did not appreciably change screening rates in older men. The Task Force acknowledges that many clinicians and patients will continue wanting screening—and these men should be supported in making informed decisions. So, in effect, the Task Force’s position is: don’t ask, don’t tell (unless asked). However, Dr. Wilt pointed out that a “C” rating, which recommends offering an intervention depending upon individual circumstances (and was used for screening mammography among women in their 40s), was not appropriate because that rating presumes evidence for a small benefit. Although my beholding of the data is perhaps biased, I believe that there is evidence for a small (long-term) benefit for screening that must be balanced against substantial (and short-term) risks for harm. Perhaps, the rating should have remained an “I” rating—insufficient evidence to recommend for or against. What I hope is that the backlash against the Task Force does not undermine the crucial message that routine screening is inappropriate and that men need to be informed about the benefits and harms of screening.
However, in the broader context of American health care, I am glad that the Task Force has stuck with its D recommendation. The public needs to understand that limited health care resources should be first allocated to the most effective interventions that achieve the most valued outcomes. The public needs to understand that many strongly-encouraged interventions have mixed outcomes, are controversial, and can actually be considered as examples of preference-sensitive care. Specialists need to recognize that there will be pushback against recommending interventions that are not evidence-based or cost-effective—interventions that informed patients might refuse to accept and that payers might refuse to reimburse. I don’t agree with the outcome of this skirmish, but I support the Task Force for waging a worthy battle.
* Publisher’s note:
Reactive rhetoric by some was raging – none more so than this tweet from UCSF urologist Matt Cooperberg:
“I hope (Task Force member) Tim Wilt knows in his heart of hearts that thousands of painful, slow, preventable deaths will be indisputably on his head.”
(Addendum on May 23: Dr. Cooperberg has now apparently removed that message from Twitter. The link – which worked when I first posted this yesterday – now is greeted by a “Sorry, that page doesn’t exist” message. But what I entered in quotes above was a direct cut-and-paste of what appeared there earlier. In fact, below are screen shots of other Twitter users retweeting Cooperberg’s original message. )
That’s similar to the vitriol employed in the past by executives of Zero – The Project to End Prostate Cancer against Dr. Otis Brawley of the American Cancer Society. One Zero exec wrote:
“Otis Brawley has killed more men by giving them an excuse to not be tested.”
Yesterday Brawley’s editorial supporting the USPSTF decision was published in the Annals of Internal Medicine. Excerpt:
“…some will continue to forcefully advocate PSA-based screening because of a blind faith in early detection. We need to practice medicine on the basis of evidence and not on the basis of faith.”
“I think (the USPSTF) process is exactly where it ought to be,’’ Brawley said. “It removes those people who have emotional, ideological, or financial conflicts of interest’’ from being on the panel. Doctors and hospitals, which get paid for performing follow-up biopsies and treatments that result from screening, have a strong interest in seeing as many men screened as possible, he added.
On CBS this morning, Brawley was interviewed along with former basketball coach Digger Phelps – who has had surgery for prostate cancer. The clip below was not aired – but is what took place in the studio during the commercial break. Sometimes that’s when the real meat of the matter is grilled.
Addendum – about 10:30 a.m. CT May 22:
The comments left in response to a CBS News article on the issue are depressing, reflecting more of the same rhetorical reactions seen in response to the USPSTF mammography recommendations in November, 2009. But some are even uglier: