David Bryan, M.D. 's Urology Blog

The United States Preventive Services Task Force (USPSTF) on Monday issued a grade “D” rating for PSA screening for prostate cancer.  Below is a synopsis issued by LUGPA (Large Urology Group Practice Association), of which I am a member.  

recommendation regarding prostate cancer screening is wrong in fact and dangerous if implemented:  an objective analysis.

Despite advances in early detection and treatment, prostate cancer remains a significant public health hazard.  Prostate cancer is the most commonly diagnosed non-skin tumor in men, and remains the second leading cause of cancer death in American males.  The USPSTF assignation of a “D” rating to PSA based screening for prostate cancer, which discourages men from undergoing screening for this potentially fatal illness, is ill-advised and irresponsible for a number of reasons:

1. The USPSTF final recommendation is fundamentally incorrect based on the scientific evidence, relying on flawed studies while refusing to properly acknowledge strong data that supports the benefits of PSA screening for prostate cancer.
   1. The USPSTF relied on the deeply flawed Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO).  This study (N Engl J Med 2009; 360:1310-1319) suffered from severe “contamination” of the data; in the first six years of the study at least 52% of men in the control arm had PSA testing.  This completely invalidates the results of the study.
   2. The largest study ever performed on screening for prostate cancer, the European Randomized Study for the Screening of Prostate Cancer (ERSPC) recently released its updated findings (N Engl J Med 2012; 366:981-990).  This demonstrated a 21% survival advantage to PSA screening for all patients, and furthermore, for those with the longest follow-up (over 10 years) this increased to 38%.  The screening efficiency of PSA testing in this study is similar to that reported for breast or colo-rectal cancer.
2. The USPSTF does not include any physicians with direct clinical experience in the management of prostate cancer, and failed to disclose the views of experts in the field when finalizing their recommendation.
   1. The USPSTF had the opportunity to review comments from the public.  During the comment period urologists, oncologists, patient advocacy groups and Congressional leaders were united in their opposition to the proposed recommendation released in October.  The USPSTF inexplicably disregarded these concerns when finalizing their recommendations.
3. The USPSTF bases their objections not on the risks of screening, which are negligible, but the risks of diagnosis and treatment of cancer.  This is a scientific bait and switch of the worst order.
   1. Screening is not diagnosis, nor is it treatment; it is a method to provide patients and their doctors with information that is then used to determine the appropriateness of further evaluation and/or treatment. 
   2. The task force’s recommendation fundamentally states that patients cannot be trusted to make informed decisions on their own. Every man has a right to make his own decision about screening after reviewing the potential risks and benefits with his own doctor. We cannot allow an unaccountable government entity to deny patients access to tests that saves the lives of thousands of Americans every year.  This issue is more than a medical issue; it is a fundamental issue of human rights.

1. Implementation of these recommendations will result in a public health catastrophe in 5-10 years.
   1. From 1972-1991, the death rate from prostate cancer increased 27%, from 30.97 deaths/100,000 men to 39.31 deaths/100,000 men. From 1991-2009 the death rate decreased to 21.99 deaths/100,000 men (44%).  As the incidence of prostate cancer has been relatively stable during this interval, the decrease can only be attributed to treatment given to patients diagnosed thanks to increased use of PSA testing after its commercial introduction in 1986; we are not detecting more cancer, we are detecting cancer earlier and saving lives.[i]

1. The 10 year survival from prostate cancer in the pre-PSA era increased only slightly, from 53.5% in the interval 1975-79 to 58.1% from 1980-84.  During the period PSA testing was introduced, 1984-89, the 10 year survival from prostate cancer improved to 69.9%.  Since that time, the 10 year survival from prostate cancer has increased every year for which we have data; by 1999 it was an astounding 98.6%.  If we fail to diagnose prostate cancer early, thousands of men who have potentially curable disease will needlessly suffer and die.[ii]

The final recommendation by the USPSTF is a one size fits all philosophy that even ignores populations universally acknowledged to be at highest risk for this disease:  African-American men and those with a family history of prostate cancer. This same task force suggested mammograms were unnecessary for women ages 40-49 and has also recommended against teaching women breast self exams, both of which were retracted after massive public outcry. The USPSTF’s recommendation risks undoing 20 years of progress in patient education; all concerned citizens are encouraged to contact their representatives to demand they overturn this inaccurate and dangerous recommendation so that no man is denied access to this potentially life-saving testing.