New England Journal of Medicine pieces on prostate cancer screening

This week’s edition of the NEJM includes four perspective pieces on the new US Preventive Services Task Force’s prostate cancer screening recommendations.

One, on “what the USPSTF left out,” states:

“Although the USPSTF explicitly does not consider costs, policymakers cannot ignore economic aspects of screening. Using data from the European screening trial, researchers have estimated that $5.2 million would have to be spent on screening (and the interventions that follow it) to prevent one death from prostate cancer. That estimate does not appear to include the costs of excessive serial PSA testing and repeated office-based encounters devoted to discussions about screening or interpretation of fluctuating PSA results. The extraordinary time, effort, and costs associated with the PSA-screening enterprise must be evaluated against other claims on health care spending and physicians’ time and energy. We believe that the current PSA-based screening paradigm does not compare favorably with competing health care priorities.”

Another, by Drs. Michael Barry and Mary McNaughton-Collins of the Foundation for Informed Medical Decision Making, argues for a grade C recommendation rather than the grade D recommendation the Task Force supports:

“A grade C recommendation would allow the patient to be involved in the decision to skip or choose a PSA screening test, after a discussion with a primary care provider about the magnitude of the known harms and the potential for some benefit. The patient could then provide his perspective on how he views the trade-off. Weighing the pros and cons to make a decision about PSA screening is an individual process, and different well-informed men will make different decisions. A grade D recommendation removes the patient from the equation and puts the physician in the central position of discouraging use of the test. Uncertainty in medicine is more common than we usually let on, and the way to address uncertainty is to allow patients the central position in decision making. A grade C recommendation would acknowledge that whereas the evidence shows that the harms may outweigh the benefits on a population level, some individual patients will still elect PSA screening. We do not believe that anyone but the patient should decide whether the small and uncertain benefits of PSA screening are worth it.

To make a grade C recommendation appropriate, we primary care clinicians must ensure there is no more routine, indiscriminate PSA screening — and no washing our hands of responsibility once the patient is referred to a specialist for prostate-cancer treatment. We owe it to our patients to provide them with the kind of guidance about this screening test that they need and deserve. That’s the way to help put the controversy to rest . . . one man at a time.”

A third piece recommended:

“PSA screening should not be dismissed as uniformly nonbeneficial. Rather, decisions about screening should be made on an individual basis, by an informed patient and his clinician, after weighing that patient’s particular risk factors.”

The fourth piece “begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author’s clinical recommendations.”

Disclosure: Drs. Barry and McNaughton-Collins work for the Foundation for Informed Medical Decision Making and the fourth piece was by Dr. Richard Hoffman who receives partial salary support from that Foundation, which also supports my web efforts.

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