By Halley S. Faust, MD, MPH, MA and Paul T. Menzel, PhD
The U.S. Preventive Services Task Force (USPSTF) recommends against prostate-specific antigen (PSA)-based screening for prostate cancer (a grade D recommendation).
This recommendation applies to men in the U.S. population that do not have symptoms that are highly suspicious for prostate cancer, regardless of age, race, or family history. The Task Force did not evaluate the use of the PSA test as part of a diagnostic strategy in men with symptoms that are highly suspicious for prostate cancer. This recommendation also does not consider the use of the PSA test for surveillance after diagnosis and/or treatment of prostate cancer.
The American Urological Association (AUA) applauds the U.S. Preventive Services Task Force for its interest in reviewing the use of the prostate-specific antigen (PSA) test. However, we are concerned that the Task Force’s recommendations will ultimately do more harm than good to the many men at risk for prostate cancer both here in the United States and around the world.
Ought there be a higher threshold of evidence for prevention recommendations than for treatment recommendations? Two prior members of the US Preventive Services Task Force (USPSTF), Robert Wallace, MD and Diana Petitti, MD, independently make this argument in the recently published Prevention vs. Treatment: What’s the Right Balance? Most recently Petitti was co-chair when the task force released its 2009 mammography recommendation. In one of the book’s chapters she relates her experience in the difficult political process following this release.
Two weeks ago the USPSTF released another politically controversial draft recommendation, this time about PSA screening. Already in 2008 the task force recommended against screening, stating:
In men younger than age 75 years, the USPSTF found inadequate evidence to determine whether treatment for prostate cancer detected by screening improves health outcomes compared with treatment after clinical detection.
In men age 75 years or older, the USPSTF found adequate evidence that the incremental benefits of treatment for prostate cancer detected by screening are small to none.
The American Cancer Society concluded the same thing last year, and changed their recommendation accordingly. The USPSTF’s 2008 recommendation for men younger than 75 was one of uncertainty about benefits and harms. Now its recommendation is stronger: there is sufficient evidence to conclude more definitively against PSA screening.
We’ll leave the details of the reasons for the USPSTF’s change from 2008 to the 2011 draft recommendation to others to fight over. Instead we’d like to point out some obvious and not-so-obvious points about other dimensions of this controversy:
1. Advocates for specific diseases tend to use anecdote to support stringent recommendations.
So, for example, they will say, “I/my brother/my husband/my father would have died if he hadn’t had a PSA test at age 53.” Such a claim may be true, and we shouldn’t discount the sympathy involved in understanding it as a personal point of view. It does not, however, provide a sound basis for policy recommen