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New USPSTF Cancer Screening Guidelines: Less Is More

Two new guidelines from the USPSTF deserve note this year, not because they recommend screening for cancer, but because they recommend limits on screening.

Based on evidence from a systematic review and a simulation model, the U.S. Preventive Services Task Force (USPSTF) recommended against colon cancer screening for people older than 85, because harms outweigh benefits. For people between 76 and 85, the task force also generally recommended against such screening, although it noted that a small benefit might be realized for some individuals (JW Oct 28 2008). In contrast to medical specialty society recommendations that were published earlier this year (JW Mar 27 2008), the USPSTF found insufficient evidence to recommend stool DNA testing or computed tomographic (CT) colonography. In a simulation model, older less-invasive tests were as effective as colonoscopy performed at 10-year intervals. Among the older effective tests were (1) annual high-sensitivity fecal occult blood testing (FOBT; e.g., Hemoccult SENSA, fecal immunochemical testing) and (2) flexible sigmoidoscopy every 5 years, with interim high-sensitivity FOBT at 2 to 3 years.

For prostate cancer screening (based on a systematic evidence update), the USPSTF took a step beyond its "insufficient evidence" recommendation of 2002 to advise against testing older men (75) because the evidence suggested that screening provides small or no benefit and known harms — erectile dysfunction, incontinence and mortality risk. In addition, whether treating men with screen-identified early-stage prostate cancer yields any long-term benefit is uncertain (JW Aug 26 2008). The insufficient evidence recommendation was retained for younger men. In other words, the USPSTF does not recommend routine prostate cancer screening.

Patients (and lawyers) often assume that more screening is better and, as a result, physicians often feel pressured to order tests. Excessive testing has become commonplace for prostate cancer screening, even for those least likely to benefit (should any benefit ever be proven). For colon cancer screening, the problem has been the opposite — insufficient testing of those who would benefit most — in part, because of the greater difficulties and inconveniences involved in testing. These authoritative USPSTF evidence-based guidelines ring true — they limit screening that has only long-term benefits (if any) for elders. These recommendations likely will be adopted by payers; such insurance payment decisions will support preventive care decisions made in the exam room that best serve our patients.

— Richard Saitz, MD, MPH, FACP, FASAM

Published in Journal Watch General Medicine December 29, 2008