Friday, June 19, 2015

The good news, at last, in prostate cancer screening

As I previously documented in a series of posts on this blog, the road to the U.S. Preventive Service Task Force's 2012 "don't do it" recommendation on PSA-based screening for prostate cancer was long, arduous, and full of political pitfalls. It led to me leaving my position at the Agency for Healthcare Research and Quality. Later, the USPSTF took heat from screening advocates in the mainstream media and in social media. The American Urological Association labeled their recommendation statement "a disservice to men" and threw its weight behind a Congressional bill (reintroduced in 2015) that would require the USPSTF to consult with "external subject matter experts" (i.e., urologists) to, in the words of one of its sponsors, "ensure that preventive care recommendations are not made in a vacuum."

In the meantime, no doubt, many primary care physicians ignored the controversy and went on doing what they had always done: ordering annual PSA tests on every male patient from age 50 until natural death, without any semblance of shared decision-making or even a discussion.

But not all. For some with the courage to embrace a medical reversal that was based on convincing evidence of harm, the Task Force's message started getting through. Some doctors began taking the extra time to tell patients about why the PSA test was a bad idea. And some of their patients listened and chose not to get the test.

The past two weeks have offered the first definitive evidence that the USPSTF's controversial stand has spared thousands of men the harmful interventional cascade that results from prostate cancer screening.

A study published on June 8th in the Journal of Clinical Oncology used information from the National Health Interview Survey to document statistically significant declines in PSA screening rates from 2010 to 2013 in men age 50 years and older. Three days later, the American Urological Association released its second Choosing Wisely list, which called on physicians to "offer PSA testing for detecting prostate cancer only after engaging in shared decision making." Not a complete about-face, but I give them credit for not dodging the issue this time around.

And a few days ago, another study in the Journal of Urology found that prostate cancer diagnoses in the National Cancer Database declined by 28 percent in the year after the release of the USPSTF draft recommendations (in October 2011). Diagnoses of "low-risk" cancers (which are almost entirely PSA-detected) fell by 38 percent, and diagnoses of prostate cancer in men over age 70 or with other life-limiting diagnoses fell by more than a quarter.

During this year's Men's Health Month, there is at last good news to report. In a rare victory for evidence-based screening, we are finally starting to roll back the burden of prostate cancer overdiagnosis and overtreatment.

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