USPSTF Finalizes Its Recommendation Against PSA Screening

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.