USPSTF Finalizes Its Recommendation Against PSA Screening

USPSTF Finalizes Its Recommendation Against PSA Screening

Despite criticism, the "D" recommendation stands.

Six months after issuing a preliminary draft recommendation against prostate-specific antigen (PSA) screening for prostate cancer, the U.S. Preventive Services Task Force (USPSTF) has finalized its position: It formally recommends against screening — a "D" recommendation in its scheme. We covered the essence of the USPSTF analysis in October 2011 (JW Gen Med Oct 27 2011). But how has the USPSTF addressed the public commentary submitted by critics in response to last year's draft recommendation (nearly 2 pages of the final report are devoted to the USPSTF's response to critics)?

Some commentators asked the USPSTF to change from a "D" to a "C" recommendation (in the USPSTF scheme, a "C" means that "Clinicians may provide this service to selected patients . . . [although] there is likely to be only a small benefit."). The USPSTF responded that it did not change to "C" because it does not concede that benefit outweighs the substantial harms.
Some commentators asked the USPSTF to provide more information about the consequences of avoiding PSA screening. In response, the new document includes a summary table showing specific numbers of potential benefits and harms per 1000 men screened.
In response to criticism that a separate recommendation for black men was not included, the USPSTF notes that "it is problematic to selectively recommend PSA-based screening for black men in the absence of data that support a more favorable balance of risks and benefits."
Some commentators believed that the USPSTF relied too heavily on the negative U.S. PLCO screening trial, which was tainted by high rates of screening outside the trial in the control group. The USPSTF responded that it also "heavily weighted" the European ERSPC trial, which had certain flaws and which showed a small mortality benefit at the expense of large numbers needed to screen and treat to benefit one person (JW Gen Med Mar 18 2009).
Responding to the assertion that screening probably is responsible for the observed decrease in U.S. prostate cancer mortality during the past 2 decades, the USPSTF replies that (a) this trend started before screening could have had an effect, and (b) many other factors, including better treatment, probably contribute to this trend.
Some commentators asked why the USPSTF did not consider effects on morbidity as well as mortality. In response, the USPSTF notes that data are simply insufficient to conclude that screening lowers morbidity or improves quality of life substantially.

The USPSTF document is accompanied by two editorials in the Annals of Internal Medicine. In one editorial, Dr. Otis Brawley, the chief medical officer of the American Cancer Society, largely agrees with the USPSTF's position. In the other, nine authors, including four urologists, disagree strongly.

Notably, the USPSTF document does not directly advise primary care physicians on handling PSA screening in real-life office practice. In fact, the document begins with the following disclaimer, which might frustrate clinicians who are looking for firm guidance: "The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision making to the specific patient or situation." When patients request PSA tests or initiate discussions about the new recommendation against screening, clinicians obviously will need to take a position one way or the other. But what about men who don't bring up the issue? For example, should clinicians who agree with the "D" recommendation still mention the PSA test — if only to tell the patient why they discourage screening? We collected readers' opinions on this recommendation. See what your fellow clinicians are planning to do in regard to these new guidelines.

— Allan S. Brett, MD

Published in Journal Watch General Medicine June 7, 2012

Citation(s):

Moyer VA et al. Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2012 May 21; [e-pub ahead of print]. (viajwat.ch/Lw6rnB)

Brawley OW. Prostate cancer screening: What we know, don't know, and believe. Ann Intern Med 2012 May 21; [e-pub ahead of print]. (http://viajwat.ch/KYqz1T)

Catalona WJ et al. What the U.S. Preventive Services Task Force missed in its prostate cancer screening recommendation. Ann Intern Med 2012 May 21; [e-pub ahead of print]. (http://viajwat.ch/LB4G6c)

Reader Remarks:

Review and add to remarks on this article

prostate CA
Sheri Bortz, 8 Jun 2012 11:14 AM EST
Specialty: General Practice
As a primary care doctor who has probably saved the life of several middle aged men with screening, I will... [more]
PSA tests
Trevor Smith, 8 Jun 2012 11:14 AM EST
Specialty: Other Specialty
Prostate cancer is the second leading cause of cancer deaths in men. The task force wishes to wait until men... [more]
USPSTF PSA SCREENING
James Engelman, 8 Jun 2012 11:14 AM EST
Specialty: Internal Medicine
We must not forget that being a physician includes both science and art. We should not discount the power of... [more]
PSA Screening
JR Crouch, 8 Jun 2012 12:45 PM EST
Specialty: Family Medicine
75 y/o male with CAD insisted on PSA, small elevation (~9), discussion, wanted USN directed Bx, done---Gleason's Grade 3 in... [more]
The wrong conclusion
Matthew R Cooperberg, UCSF, 11 Jun 2012 12:16 PM EST
Specialty: Oncology
Beyond the headlines, the article by Moyer et al demonstrates a profoundly poor understanding by the USPSTF of both prostate... [more]
Prostate CA Screening
Bernard A. Yablin, ret sst clin prof URMC, 11 Jun 2012 12:16 PM EST
Specialty: Pediatrics
I am almost 84yo and regular psa and dre were stopped some 3 years ago without the ACS recommended mutually... [more]
PSA screening
Roger J. Beneitone, Westfield ,MA, 14 Jun 2012 12:56 PM EST
Specialty: Internal Medicine
I tend to discourage screening for prostate cancer and mention the all too common complications of biopsy and treatment (pain,... [more]
USPSTF PSA SCREENING
E. Monteoliva, H.Dr.R.Lafora, 14 Jun 2012 12:56 PM EST
Specialty: Internal Medicine
I think PSA screening is beneficial for older (more than 75 y.o.) men, and will probably reduce morbimortality in these... [more]
CAN'T TELL WHO IS SAVED
Michael J. Kelly, 14 Jun 2012 12:56 PM EST
Specialty: Family Medicine
Out dilemma is that we mostly don't know if we have saved anyone. The evidence suggests we are on unsure... [more]
Snake Oil - Category D
Steven Leiner, 18 Jun 2012 7:35 AM EST
Specialty: General Practice
Dr. Brett wonders if we should still discuss Category D recommendations with patients. Many useless tests and interventions are deemed... [more]
psa screening
Palmer F. Meek, Primary care office, 19 Jun 2012 1:24 PM EST
Specialty: Internal Medicine
If PSA screening does more harm than good should we also abandon the DRE? I've seen no mention of Gleason... [more]
PSA screening
Nayvin Gordon, oakland California, 5 Jul 2012 8:22 AM EST
Specialty: Family Medicine
I was in my private Family Medicine Practice in Oakland, California for 25 years. i used the PSA to screen... [more]
USPSTF "FINAL" RECOMMENDATION
Robert C Preston, MD, Repid City, SD, 5 Jul 2012 8:22 AM EST
Specialty: Urgent Care Medicine
For a physician who has Gleason 6 prostate CA, who currently is under active surveillance by my urologist at the... [more]
PSA screening
James E. Baker, Conroe, Tx, 5 Jul 2012 8:22 AM EST
Specialty: Family Medicine
The PSA is an imperfect test which has helped reduce prostate cancer mortality. I will still recommend that my patients,... [more]
PSA Testing
E. Louis Priem, Bassett Healthcare, Cooperstown, NY, 12 Jul 2012 10:35 AM EST
Specialty: Critical Care Med (Int Med)
As an MD with prostate CA and a carrier of the Ataxia telangectasia gene, I wanted to have PSA testing.... [more]
Stop PSA screening
John GILBERT, Ireland, 17 Jul 2012 12:58 PM EST
Specialty: Family Medicine
If a man has outflow symptoms, you have to screen his prostate. If he hasn't:

- we don't have a... [more]
Clinicians should decide on PSA.
segaran xavier, 20 Jul 2012 12:21 PM EST
Specialty: Family Medicine
It is a definite no,no as a screening tool.Done along with DRE it is a valuable tool in assisting the... [more]
Post prostate cancer surgery
merv mcallister, 30 Jul 2012 11:15 AM EST
Specialty: Neurology
Hi I am a 57yo male in the health field post radical prostatectomy with a Gleason score of 4/3 I... [more]
PSA is a SELECTIVE and should be use at PHYSICIAN discretion
Ed.C Hoffman, 21 Dec 2012 12:19 PM EST
Specialty: General Preventive Medicine
Is not the PSA one reading what really count is a dramatic change of the reading factor from one year... [more]

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