Yesterday the US Preventative Services Task Force (USPSTF) issued the final version of its recommendation against routine screening for prostate cancer, believing that screening does little good and but substantial harm, mainly due to side effects of unnecessry treatment.
Here is what a reporter from the Washington Post highlighted in his article about it: "... the task force concluded such testing will help save the life of just one in 1,000 men...." That point is based on analysis of two studies that played a dominant role in USPSTF thinking, the PLCO trial (Prostate, Lung, Colorectal and Ovarian) and the ERSPC trial (European Randomized Screening for Prostate Cancer). Both those trials have been previously discussed on this Board, from the time of initial publication in 2009, and both have been updated based on more years of following patients in the trials.
However, the essential, critical flaw remains the same for both, even after the additional follow-up: inadequate follow-up time to allow visibility of the extent of benefit, specifically deaths avoided. The Task Force clearly recognizes that typically prostate cancer patients will survive from diagnosis for more than a decade, but it fails to connect the dots and see that this means follow-up in trials, in order to gauge the extent of survival benefit, must be years more than a decade!
Instead, the Task Force relies on follow-up from time of enrollment in the trials rather than from time of diagnosis. The consequence is that the follow-up periods in the PLCO and ERSPC trials on which the Task Force is resting its case are simply far too short to be meaninful! Therefore, concluding that testing will save the life of just one in a thousand men is a premature and unwarranted conclusion.
I am not completely surprised the Task Force failed to come to grips with this mistake and many others in its draft report, but I am disappointed. Its draft report was so misleading that many in the prostate cancer community had doubts whether the Task Force was competent to understand the disease and come to correct conclusions. However, the Task Force requested and received public comment, in fact receiving a mountain of critical responses, and I had some hope that the comments would enable the Task Force to alter its recommendation. However, modern medicine is a highly specialized enterprise, and no voting member of the Task Force treats prostate cancer in their medical practice. As I read the final recommendation, I again saw the signs that were in the draft version that the Task Force has a fundamentally limited understanding of prostate cancer. I'm reminded of the old saying that "A little knowledge is a dangerous thing."
The Task Force is essentially concerned with the problem of overtreatment and resulting harms. The problem of overtreatment of prostate cancer is real, as is widely acknowledged in the medical community that is familiar with prostate cancer. However, the wise solution, as I see it, is not to cease screening, rather it is to employ the now proven strategy of active surveillance for men with low-risk case characteristics. That solution has been strongly endorsed by highly influential professional medical organizations like the American Urological Association. While the Task Force understands the mechanics of what active surveillance involves, the Task Force does not address the key role of active surveillance in solving the overtreatment problem. In other words, the solution the Task Force should have found is to use our power to observe and think rather than emulate the ostrich and stick our heads in the sand.
I have posted general points here, but I can provide detailed backup information.
One way or another, the Task Force recommendation needs to be withdrawn. The Task Force missed a great opportunity to join in the endorsement of active surveillance.