Gary Kirsh, MD
A United States Preventive Services Task Force (USPSTF) recommendation against the use of prostate specific antigen (PSA) testing needs to be updated, said Gary Kirsh, MD, president of the Large Urology Group Practice Association (LUGPA)—a professional association representing more than 20% of the nation’s practicing urologists. The task force gave the screening test a grade of D, meaning that there is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.
“This was a travesty,” said Kirsh, in an interview with OncLive.com
. “Their interpretation of the literature with regard to PSA testing is hotly disputed by many experts in the field,” he said. “In the era of PSA testing, we have seen a 40% reduction in prostate cancer mortality in the United States.”
Kirsh contends that when the recommendation was first issued in 2011, the task force failed to take into account evolving trends in the thinking of urologists regarding the PSA testing and prostate cancer treatment. In years past, when a patient had an elevated PSA level, it might automatically have resulted in a prostate biopsy. A positive cancer result from a biopsy may have led to immediate surgical or radiation treatment.
“But the practice of medicine has evolved,” Kirsh said. “Now, if a patient has an elevated PSA, we look for a trend, or we can consider other mitigating factors that influence the decision to have a biopsy. If the cancer has a low or very low risk, many patients are going on active surveillance protocols. The recommendation does not recognize the current treatment paradigm. But not performing a PSA could lead to prostate cancer being identified at later, more aggressive, stages.”
Now, legislation proposed by Representatives Marsh Blackburn (R-TN) and Bobby L. Rush (D-IL) has galvanized 3 of the nation’s largest urology associations to support their bill to reform the way the USPSTF reviews and makes recommendations for clinical preventive services to primary care physicians. The USPSTF Transparency and Accountability Act of 2015, HR 1151, would reform the task force by requiring a balanced and relevant representation of medical personnel, requiring members to disclose conflicts of interest, and requiring consultation with those who treat the specific disease in question. The other groups in support of the legislation are the American Association of Clinical Urologists (AACU) and the American Urological Association (AUA).
The failure of the current system is underscored by recent data demonstrating the deleterious impact of the USPSTF recommendation against PSA screening. Researchers found that between 2011 and 2013, in the immediate wake of the USPSTF recommendation, there was a 6% increase in the diagnosis of intermediate or higher risk prostate cancer in men and concluded that many more deaths could result from this disease.1
They made no determination whether a decline in PSA screening was the cause.
The recommendation has also affected policy, said Kirsh. “Some commercial payers are denying coverage for PSA testing. It’s going to affect patient outcomes in the long run.”
Other changes proposed in the legislation include publishing a draft research plan to guide the systemic evidence review process; considering findings and research by federal agencies and departments; and making the evidence review available for public comment. Currently, the only research plan that is available for public comment on the USPSTF web site has to do with healthful diet and physical activity for cardiovascular disease prevention.2
“I am concerned that decisions are being made without proper input from the specialists who treat these diseases,” representative Blackburn said in a statement. “Our legislation would require common sense coordination among relevant agencies and stakeholders while protecting the doctor-patient relationship.”
“This bill will bring the appropriate specialists and stakeholders to the table, and add clarity to the process of making recommendations on the preventative services that should be available to the American people, said representative Rush.
The task force is made up of 16 volunteer members who are experts in prevention, evidence-based medicine, and primary care. Their fields of practice and expertise include behavioral health, family medicine, geriatrics, internal medicine, pediatrics, obstetrics and gynecology, and nursing. Task force members are appointed by the director of the Agency of Healthcare Research and Quality (AHRQ) to serve 4-year terms.
Hall MD, Schultheiss TE, Farino G, et al. Increase in higher risk prostate cancer cases following new screening recommendation by the US Preventive Services Task Force (USPSTF). 2015 Genitourinary Cancers Symposium. J Clin Oncol. 2015;33 (suppl 7). Abstract number: 143. Available here: http://meetinglibrary.asco.org/content/140836-159.
US Preventive Services Task Force. Opportunity for comment. Available here: http://www.uspreventiveservicestaskforce.org/Page/Name/us-preventive-services-task-force-opportunities-for-public-comment. Accessed March 10, 2015.