Today, the U.S. Preventive Services Task Force finalized its provisional recommendation to assign PSA-based screening for prostate cancer a "D" (don't do) grade in men of any age. The USPSTF's conclusion from five randomized, controlled trials that PSA-based screening produces no health benefits is consistent with a Cochrane for Clinicians review that AFP published more than a year ago. Evaluating the entire body of evidence, the Task Force concluded:
The reduction in prostate cancer mortality after 10 to 14 years [from PSA-based screening] is, at most, very small, even for men in what seems to be the optimal age range of 55 to 69 years. ... In contrast, the harms associated with the diagnosis and treatment of screen-detected cancer are common, occur early, often persist, and include a small but real risk for premature death. ...The inevitability of overdiagnosis and overtreatment of prostate cancer as a result of screening means that many men will experience the adverse effects of diagnosis and treatment of a disease that would have remained asymptomatic throughout their lives. ... The USPSTF concludes that there is moderate certainty that the benefits of PSA-based screening for prostate cancer do not outweigh the harms.
Few family physicians still perform screening flexible sigmoidoscopies, and PSA is one of the most commonly ordered blood tests in men over 50. How long will take to change both of these practices to reflect the best evidence?
Excellent post! The "good news":
ReplyDeletei) PSA finally assigned an appropriate screening recommendation (ie, "D" rating = Don't Do in asymptomatic subjects!).
ii) The fact that Health Maintenance/Cancer Screening remains an "ongoing work" - with recommendations evolving as evidence comes in. CREDIT to USPSTF for updating their recommendations.
Important to recognize the "mixed bag" with all of these interventions. Assignment of a "D" recommendation for PSA screening does not take away from the seriousness of prostate cancer as a potentially life-threatening disease. It merely recognizes that overall, more harm than good is done by screening asymptomatic subjects ... (that said in full realization that there are some men whose lives were saved by screening ... ).
As positive as the results on colorectal cancer are - it is important to recognize that it too is a "mixed bag". On the positive side is that lives CAN be saved by it - so it clearly merits inclusion as one of the screening tests that can be effective. But there are "negatives" of screening with colonoscopy. These include: i) cost (even if "covered" - expense may be ~ $1,000 in some communities by the time all of the bills come in); ii) risk of perforation (approx 1/1,000 procedures); and iii) risk of NOT being "covered" anymore for colorectal cancer if a "benign polyp" is found and removed on this screening exam.
Number iii) is deserving of comment - based on personal observation of a case well known to me when the "excellent insurance company" refused to cover this otherwise healthy patient who followed recommendations for screening colonoscopy and had a very small, benign polyp that was removed. She was subsequently told that her insurance would NOT cover her in the future in the event she developed colorectal cancer .... Her "bottom-line": i) She was out ~ $1,000 (not covered by her insurance for pathology fees, doctors fees, etc); and ii) her exam was "benign" - BUT - she no longer has insurance coverage in the event she does develop colorectal cancer in the future. QUESTION: Is she better off for having been screened?
The above contributed simply to present another view. Screening is far from perfect. A balance must be struck between potential for benefit vs potential for harm. "Harm" may come in many forms (ie, the above case). NNS ("number-needed-to-screen") to produce benefit might be one way of more accurately presenting the pros and cons of various screening tests to patients when seeking "informed consent". Finally - the medical community needs to become better informed of some "hidden harms" (like the fact that NO ONE in any physician's office was able to accurately convey HOW MUCH the colonoscopy would cost this patient - until the bills not covered finally stopped coming - AND - Why do a screening test if a benign finding might exclude your patient from subsequent coverage for the very condition they are worried about .... ).
THANK YOU for listening!