Radiation oncologists against new USPSTF prostate cancer guideline

The United States Preventative Services Task Force issued a new guideline in May recommending against PSA screening for prostate cancer altogether.  This government based panel has been getting the deserved pushback from the American Medical Association (AMA) as well as from the American Urological Association (AUA).  


Here's a prior blog post with my thoughts on this as well as the AUA response with current PSA screening guidelines from the AUA as well the American Cancer Society.


I wanted to share in this post a statement from the American Society for Radiation Oncology (ASTRO).  These doctors are on the front lines with us (urologists) in fighting prostate cancer.  ASTRO also has lined up against the new USPSTF guidelines.  

ASTRO statement

My analysis:


I agree with Dr. Gunderson's quote on this issue.  There certainly is an over diagnosis issue with prostate cancer.  However, as active surveillance is becoming a viable method to keep track of the disease, advocating for a wholesale cessation of PSA based screening is like throwing out the baby with the bathwater.


Dr. Sandler also makes a great point in the release. The prostate cancer screening issue is not a problem that a cookie cutter approach can solve.  With multiple factors such as age, expected longevity, race, symptoms, and family history, each situation is unique and each man should have the opportunity to make an individual informed decision on the matter with his physician.

AMA tells USPSTF to incorporate specialists in guideline creation

Resolutions were passed at the American Medical Association House of Delegates Meeting admonishing the USPSTF regarding their screening guidelines on mammography and PSA screening.


Here are the passed resolutions: (Source: AUA e-mail alert)

RESOLVED, That our AMA expresses concern regarding recent recommendations by the USPSTF on screening mammography and PSA screening and the effects these USPSTF recommendations have on limiting access to preventive care for Americans.

RESOLVED, That our AMA encourage the USPSTF to implement procedures that allow for meaningful input on recommendation development from specialists and stakeholders in the topic area under study.

Here is coverage from ABC News on the topic. 


The recent USPSTF guidelines for PSA screening were done without the input from the American Urological Association.  This is a big tripping point for me on the guidelines since we urologists are the main doctors who take care of men with prostate cancer.


Further, the USPSTF membership lacks oncologists and urologists. Here are the current members of the USPSTF: 


I applaud the AMA for taking a stand on this. Specialists represent a great resource for the crafting of these guidelines and need to be involved at the ground level, not after the fact.  Not involving main stakeholders who implement such guidelines reduces buy-in from the medical community as well as patients.

My take on USPSTF final prostate cancer screening guidelines

The US Preventive Services Task Force (USPSTF) released its final prostate cancer screening guidelines on May 21st, 2012, during the American Urological Association Annual Meeting (curious timing...in my opinion).


The task force recommended against PSA-based screening altogether for prostate cancer by giving the practice a "D" rating.  From the USPSTF grade definitions site this means: "The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits."  The task force suggests that healthcare providers: "Discourage the use of this service." This recommendation is no different than the draft recommendations issued in October, 2012 despite vocal opposition from many sources.


The American Urological Association (AUA), American Cancer Society (ACS), and National Comprehensive Cancer Network (NCCN) have issued guidelines recommending men to have discussions with their healthcare providers regarding the risks and benefits of prostate cancer screening.


AUA Guideline
ACS Guideline
NCCN Guideline


The AUA has expressed its vigorous opposition to the the final USPSTF recommendation.  AUA President, Dr. Sushil Lacy, released this statement about it on behalf of its members.  The AUA also has a website about the issue and prepared a fact sheet about PSA testing for its members.


My take:
The PSA screening controversy is a complex issue.  There are many factors involved in screening such as age, expected longevity, race, family history, and urologic symptoms.  I believe that at this time, the USPSTF blanket recommendation is too simplistic.  I urge men to talk further with their healthcare providers regarding this issue and consider referral to a urologist if there are still lingering questions about prostate cancer screening.  Also, the diagnosis of prostate cancer does not necessarily mandate treatment.  Depending on the clinical scenario, monitoring of the disease or "active surveillance" can be a viable option for many men.

Warren Buffett and President Obama vs. USPSTF guidelines

As an 81 year old man, it's ironic that Mr. Buffett is in the demographic that the United States Preventive Services Task Force (USPSTF) recommends against screening.  The current official recommendation from this body is that people aged 75 years of age or older should not be screened.

USPSTF prostate cancer screening guideline - 2008 (in revision)

This guideline is old and their current draft guidelines advise against screening altogether.  This new proposed guideline was released in October, 2011 and had two comment periods after release.  Their final recommendation is pending.

USPSTF draft guideline against all screening for prostate cancer

The new proposed guideline has drawn the ire of many groups, with the American Urological Association leading the way.

AUA page with USPSTF response

I too have been involved in the response, sending an editorial to the Concord Monitor.  In particular, I detail the interesting fact that while this controversy is going on that President Obama just had a PSA test. If the new draft guidelines were used, he would be advised against having the test.  I feel that he should have the test and continue to do so, especially since he's in an at-risk demographic by being African-American.

As stated in my prior blog post about Warren Buffett's cancer, I think using age alone is a very simplistic cutoff.  Prostate cancer is quite complex and the medical data is still evolving.  There is little controversy that there is a problem with the over diagnosis of prostate cancer.  However, diagnosis does not necessarily mean treatment.  One good aspect of this controversy is that there is more awareness that many men have very low risk disease and can be managed with active surveillance.

The bottom line is that we currently don't know which patients with prostate cancer will die of that disease.  Until this issue is further clarified with more clinical studies or a breakthrough in prostate cancer detection, men should have an informed discussions with their doctors regarding this issue on a case by case basis.  It is premature for the USPSTF to issue such a blanket statement that affects the health of millions of men in the United States.