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To screen or not to screen?

To screen or not to screen? One of the more “interesting” experiences of my journalistic career was co-authoring an Op-Ed for the San Francisco Chronicle in 2002 on the lack of evidence for prostate cancer screening using the PSA test.

The piece caused quite a reaction, which we later discussed in the BMJ:

“Within hours of our piece being published, prostate cancer charities, support groups, and urologists around the country had circulated a "Special Alert" by e-mail. This community has huge faith in PSA tests, and it did not care for our opinion. The e-mail, under the header "ATTENTION MEN!!" urged the community to take action. By the end of the day, accusations, abuse, and personal threats jammed our e-mail inboxes. We were compared to Josef Mengele, and accused of having the future deaths of hundreds of thousands of men on our hands.”

I suspect that this same community will now be up in arms about the latest guidance from the US Preventive Services Task Force (USPSTF), one of the best respected independent health agencies in the country.

As the New York Times reports in a huge cover story today, headlined Panel Urges End to Prostate Screening at Age 75, the task force has systematically reviewed the best evidence on the value of such screening and concludes:

“The USPSTF recommends against screening for prostate cancer in men age 75 years or older.”

It also concludes that “the current evidence is insufficient to assess the balance of benefits and harms of prostate cancer screening in men younger than age 75 years.”

The New York Times notes that the new guidance, which now clearly advises against screening men aged 75 and older, represents "an abrupt policy change by an influential panel," a panel that had previously withheld giving specific advice regarding screening for prostate cancer.

In a terrific NPR commentary today on the new guidance, Doug Kamerow says:

“There just aren't any good studies to show that men who get screened and treated for prostate cancer live longer than those who don't. So the benefits are unknown. But the harms of screening and treatment are real and well documented. They include not just the costs and pain of treatment, but also the incontinence and impotence that some men get after surgery. The problem is that some prostate cancer grows quickly and is lethal. Some, especially in older men, is slow-growing and never causes a problem. That is why people say that more older men die with prostate cancer than of prostate cancer.”

I suspect that despite the new USPSTF guidance, the “great prostate debate” is far from over. It is merely, says NBC news’ chief science correspondent Robert Bazell, “the latest shot in an ongoing war among many factions who hold various positions on this disease.”

Hopefully the war will be settled when we have the results of two ongoing clinical trials of prostate cancer screening, one in the U.S. and one in Europe.

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