USPSTF Meeting Canceled: Coincidence or Ominous Precedent?

This article originally appeared online at DrPullen.com.

Does the postponement of the meeting of the United States Preventative Services Task Force (USPSTF) that was scheduled to take place on November 1-2, just prior to the national elections, seem like more than a coincidence? The USPSTF had discussion and a vote on the controversial subject of routine PSA testing for men age 50-75 on the agenda for this meeting. Currently the USPSTF has an “I” recommendation for PSA testing in this age range. At the meeting of the USPSTF in November last year the group initially voted to recommend against routine PSA testing (give it a “D” recommendation) but then decided that a review of the possible harms of screening also needed review in light of new studies, and so re-voted to postpone any recommendations until that review could be accomplished. The new information was to be reviewed at this November meeting.

Last November, the USPSTF voted to change their recommendation on mammography in the 40-50-year-old female age group from a routine screening test to a test they recommended for all women in this age group, to a test that should be discussed with their physician to decide if the individual patient wanted the test given the increased risks of false positive testing complications of this testing. This recommendation came under great criticism from the press and breast cancer groups. The USPSTF was caught off guard, and in the aftermath of this flood of criticism they changed their protocol — they will now have a four-week period during which drafts of all planned revisions to recommendations will be posted on their website. These are to be posted for public comment prior to formal publication of the recommendations. This is designed to allow outside experts, the media, and the public to have an opportunity to make comments on the recommendations prior to them taking effect.

Prior to the recent Health Care and Education Reconciliation Act of 2010 these recommendations, though very useful to physicians, carried little weight. The health care reform bill mandates that USPSTP preventative recommendations carrying a recommendation of A or B must be covered by insurance policies, but does not mandate coverage of preventative services with an “I” recommendation. Prostate cancer is a very emotional subject for many men, and there has been a lot of optimism that early detection by PSA testing would allow men to have prostate cancer detected early, and by receiving early treatment expect longer lives and less morbidity. Unfortunately, despite many studies on this topic, there remains a great deal of debate as to whether PSA screening of men age 50-75 leads to better outcomes. There are likely many reasons this has been difficult to prove or disprove. These problems include:

• Prostate cancer can sometimes be present for many years without much progression and these men may live a long and healthy life without even knowing they have a prostate cancer. Other men have more aggressive cancers that progress and lead to premature death. We are not good at knowing what the course of a cancer in any given individual may take.
• The evaluation of an elevated PSA usually includes a prostate biopsy, which in itself can lead to complications of infection, sometimes a serious infection.
• The treatments for prostate cancer often have significant risks, including urinary incontinence, erectile dysfunction (up to >50% in some studies), and death.
• Treatment of advanced prostate cancer is often fairly good, making it more difficult to know if early treatment, with its risks and complications, is better than not knowing you have the cancer for possibly many years, then receiving treatment for later stage disease after symptoms occur.

Many physicians (me included) agree that it is difficult to know if we are saving lives or preventing morbidity by screening and early detection of prostate cancer. That’s not really my point in this article. What really bothers me is that the USPSTF has been highly respected as a group that objectively examines all the evidence and makes recommendations based on the best science and data available, and now may now be bowing to political pressure. Maybe the comment by Ned Calonge, the chair of the 16-member USPSTF, that the meeting was postponed just prior to the elections due to scheduling conflicts is the real explanation. Maybe it’s just a coincidence that it was put off until after the elections, but it seems ominous that in the aftermath of the criticism that came after the breast cancer screening recommendations that this happened at this particular time.

Physicians and the American public need to have confidence that the USPSTF is making the best recommendations based on the best data available, and not having their recommendations be suspected of being swayed by political pressure.

Ed Pullen, MD, is a board-certified family physician practicing in Puyallup, WA. He blogs at DrPullen.com — A Medical Bog for the Informed Patient.

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