Monday, February 28, 2011

PSA testing: will science finally trump politics?

Maybe the third time will finally be the charm.

In early November 2009, the U.S. Preventive Services Task Force voted unanimously to update its 15-month old recommendations on screening for prostate cancer in men younger than 75, changing its previous rating of "I" (insufficient evidence) to "D" (recommends against). But after a shocking political firestorm erupted over the Task Force's new recommendations making mammography optional for women in their 40s, it decided to postpone finalizing the new statement pending a more precise estimate of the harms inflicted by indiscriminate PSA testing. As a medical officer at the Agency for Healthcare Research and Quality, I personally wrote the evidence review upon which the USPSTF based its initial recommendations and helped to commission and oversee an independent report of the harms of prostate cancer treatments authored by one of AHRQ's Evidence-Based Practice Centers.

The USPSTF scheduled its "re-vote" on prostate cancer screening for its November 2010 meeting. As reported in the Wall Street Journal and on this blog, the Task Force was forced to cancel that meeting due to the unfortunate "scheduling conflict" with the critical midterm Congressional elections. The flagrant interference by White House officials in the work of this independent expert panel reflected not only a one-time political calculation, but the culmination of nearly a year of meddling with the timing of release of other potentially controversial scientific statements, as I've documented here, here, and here.

In the meantime, a virtual mountain of evidence was accumulating against PSA testing to detect prostate cancer. Two independent meta-analyses of randomized trials of population-based screening published last year in BMJ and the Cochrane Library concluded that routine screening had little to no health benefits and could not be recommended. Dr. Richard Ablin, who invented the PSA test in 1970, wrote an Op-Ed in the New York Times that labeled PSA testing a "profit-driven public health disaster" and called on the medical community to "confront reality" and stop using the test routinely. And just last week, a rigorous analysis published in the Journal of the National Cancer Institute convincingly dismantled the commonly held belief that PSA velocity, or the rate of rise in PSA in successive tests, could be used as an indication for prostate biopsy in men with normal PSA levels.

On March 10 and 11, the Task Force will meet in person for the first time in eight months to once again take up prostate cancer and several other topics that were unable to be addressed due to its previous meeting's cancellation. I no longer work for AHRQ and have had no involvement in planning this meeting. It is my sincere hope, however, that neither the USPSTF nor the federal government will be cowed by the prospect of triggering another political firestorm into soft-pedaling the scientific evidence that PSA testing does more harm than good.


  1. One of my favorite topics. Thanks Kenny. I provide a very scripted. Description of "the known harms and possible benefits" of PSA testing to my 50-74 year old male patients. Most ask me why are you even offering it? Which either means my bias is coming through or really I am presenting it accurately, why am I. The Answer is Lawyers and politics, surely not science. Of course the other challenge is the disconnect they hear from popular press as well as the urologists who ax a group still strongly advocate for PSA testing. Add that to the popularized real experience of Dr. Merensteins experience in the JAMA article "Winners and Loosers"(sorry no hyperlink) describing the legal consequences he suffered regarding failure to dx cancer by doing Just what guidlines stated. Fear of being sued keeps doctors ordering this test. A few good lawsuits Against Pcps and urologists for creating harm from screening might reverse this trend and let evidence prevail.

  2. Thanks, Dr. Lin. Agree. We also summarized the evidence at our EBM website, Prostate Specific Antigen (PSA) Test to Screen for Prostate Cancer.

  3. You all may be interested in our (free downloadable book) Let Sleeping Dogs Lie: What men should know before being tested for prostate cancer. Sydney University Press 2010. It has topped the download list 4 months straight.
    Simon Chapman
    Professor of Public Health

  4. At the risk of piling on, great post, Kenny!

  5. Thanks for the support, friends. Here is a link to Dan Merenstein's JAMA piece "Winners and Losers" that Steve Schwartz mentioned: