Whose Head is in the Sand Now?

head-in-sandIn 2011, the United States Preventive Services Task Force (USPSTF) decreed, without benefit of input from urologists or oncologists, that PSA blood tests were leading inexorably to over-treatment for prostate cancer and stated that PSA screening should be halted for most men. In February 2013, I wrote that Consumer Reports Magazine had become the lapdog of USTSPF by answering its question, “do the benefits of the PSA test outweigh the harms?” with “very unlikely.”

The USPSTF effectively said it was better to have American men stick their heads in the sand and forego the PSA test altogether rather than do what the American Urological Association recommended: continue PSA testing, but encourage men and their doctors to have a substantial in-depth conversation about the benefits and risks of prostate biopsies and cancer treatment.

Because prostate cancer grows quietly and slowly, usually without symptoms, many prostate cancer organizations warned that eliminating PSA screening among the population would lead to greater numbers of unscreened men appearing at their urologist’s office with advanced prostate cancer–too late for a definitive cure.

At the Genitourinary Cancers Symposium held in February 2015 in Orlando, Florida, Dr. Timothy Schultheiss of City of Hope Hospital, Duarte California, stated, “Our study was the first to measure the changes in prostate cancer presentation in the period following the US Preventive Services Task Force (USPSTF) prostate-specific antigen (PSA) screening recommendations [in 2011].”* What he reported suggests that it is the USPSTF and the editorial staff at Consumer Reports that have their heads in the sand.

An analysis of data on roughly 87,500 men treated for prostate cancer since 2005 that showed “a notable increase in higher-risk cases of the disease between 2011 and 2013.” Between 2005 and 2011 the number of men with PSA levels >10 (a level that makes doctors suspicious cancer may be present) was decreasing each year. But between 2011 and 2013, “the proportion of men diagnosed with intermediate- or high-risk cancer, based on blood PSA level, increased by 3% per year without evidence of a plateau.”

In other words, less than four years after the USPSTF declaration and just two years after Consumer Reports blithely dismissed the necessity of PSA screening, the warnings of increased prostate cancer occurring in the population have proved correct.

Dr. Schultheiss calculated that based on 233,000 new prostate cancer cases predicted for 2014 by the National Cancer Institute, 14,000 more men would be diagnosed with high risk prostate cancer than were diagnosed in 2011. Worse, “the investigators predicted that at least 1400 additional men might die from prostate cancer each year” than would have been the case before PSA screening was declared unnecessary and even harmful.

So, telling men that ignorance about the state of their prostates is preferable to knowing even their baseline PSA has resulted in more men being diagnosed with advanced prostate cancer and more men dying. This trend will doubtless continue unless the USPSTF rescinds or modifies its position.

Not only is this egregious public health policy, it reflects a breathtaking condescension on the part of the USPSTF and its editorial lackeys that men are just too stupid and their doctors just too greedy that they would do anything other than proceed without hesitation to biopsies and treatment based on the results of a single PSA test. Apparently, it never occurred to them to consider that a raised PSA level might actually be the beginning of intelligent conversation between doctor and patient. 

What would the breast cancer advocacy community be doing if eliminating screening had led to increased breast cancer diagnoses and more deaths each year? I think I already know the answer to that question.

*http://www.practiceupdate.com/news/6914/32/1 accessed 3/3/15

Comments

  1. Greg Hoffman says

    Well, Craig, it certainly didn’t take long to have measurable data to question the “wisdom” of the USPFTF and Consumer Reports opinions. Sadly, more men will be at risk than necessary. Why is it that organizations with such public forums want to dumb down so many important issues, not just health in general or prostate cancer specifically, but so many facets of American life. Are losing our way? WHy haven’t the colleges of medicine done a better job of inculcating a sense of total treatment of the patient. Discussion, education, listening and opportunities for early intervention for desease prevention seem to falling by the wayside. Thanks for these informative posts, Craig.

  2. says

    Greg,

    The short answer to your questions is: money.

    As long as we retain a system based on private health insurance companies and their rules rather than on health care, it will always be about money.

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