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USPSTF Policies Questioned
  AMA Bucks USPSTF on Mammography

By Emily P. Walker, Washington Correspondent, MedPage Today
Published: June 19, 2012

CHICAGO -- The American Medical Association's House of Delegates has come out in support of screening mammography for women starting at age 40.

The new policy is in conflict with the controversial 2009 recommendation of the United States Preventive Services Task Force (USPSTF) that routine screening mammography for breast cancer was unnecessary in women younger than 50.

The House of Delegates stopped short of recommending that "every woman should get routine screening mammograms every year starting at age 40." Strongly debated in Tuesday morning's session, that language was rejected by the delegates in favor of a lighter "should be eligible" phrasing.

In a further slap at the federal task force, the House of Delegates voted to adopt a resolution stating that the AMA "expresses concern regarding recent recommendations by the USPSTF on screening mammography and prostate specific antigen (PSA) screening and the effects these recommendations have on limiting access to preventive care for Americans."

The firestorm that followed the USPSTF recommendations attracted congressional attention from legislators, and HHS Secretary Kathleen Sebelius eventually issued a statement emphasizing that the USPSTF does not set health policy.

A number of medical groups, including the American Cancer Society, the American College of Radiology , and the American Congress of Obstetricians and Gynecologists disagreed with the USPSTF recommendations and said women younger than 50 benefit from having routine mammograms.

The USPSTF again set off a controversy in 2011 when it said that healthy men do not need prostate cancer screening with prostate specific antigen (PSA) because the test does not save lives and often leads to unnecessary testing, interventions, and treatment. The conclusion came after the USPSTF reviewed data from five large randomized clinical trials of PSA testing, which all found found no mortality benefit among men who underwent screening PSA testing and were followed for 10 years.

The PSA recommendation has been controversial in the medical community, especially after a major European trial showed routine testing in healthy men resulted in about a 21% reduction in the rate of prostate cancer deaths after 11 years of follow-up.

In both instances, speciality medical societies were not happy that they weren't involved in drafting the cancer screening guidelines, and on Tuesday, the AMA adopted another policy encouraging the USPSTF to implement procedures that "allow for meaningful input" from specialists.

The USPSTF is an independent panel 16 volunteer members, most of whom are clinicians in primary care or preventive medicine.


PSA Testing Still Has Value, Trial Suggests

By Michael Smith, North American Correspondent, MedPage Today
Published: March 14, 2012

The controversy over prostate cancer screening seems likely to continue with publication of a major European trial that continues to show a benefit with routine testing in healthy men.

After 11 years of follow-up, screening resulted in about a 21% reduction in the rate of prostate cancer deaths, Fritz Schršder, MD, of Erasmus University Medical Center in Rotterdam, the Netherlands, and colleagues reported in the March 15 issue of the New England Journal of Medicine.

The findings in the European Randomized Study of Screening for Prostate Cancer contradict those of the NIH-sponsored Prostate, Lung, Colorectal, and Ovarian (PLCO) screening program, which has consistently reported no benefit to using prostate specific antigen (PSA) screening in healthy men.

And they leave practitioners in an "unsatisfactory situation" in which they may feel there is not yet enough data to abandon PSA screening, according to Anthony Miller, MD, of the University of Toronto.

In an accompanying editorial, Miller argued that the PLCO analysis is more likely to reflect the situation in the U.S. for a range of reasons, including the high background rate of PSA testing.

For that reason, he said, it would be "unwise" to increase PSA testing in the U.S. and doctors would be well advised to follow the preliminary recommendations of the U.S. Preventive Services Task Force.

Last October, the task force said that healthy men don't require routine PSA testing because the test does not save lives and often leads to unnecessary testing, interventions, and treatment.

The European trial includes 182,160 men from eight countries, who were between 50 and 74 years old when they entered the study. They were randomly assigned to PSA screening or no screening and followed for an average of 10.5 years and a median of 11.

In a previous report, Schršder and colleagues said they had observed a 20% relative reduction in prostate cancer mortality risk after nine years of follow-up, with PSA testing every four years on average.

Those findings have not changed much with the additional two years of follow-up.

The relative reduction in the risk of death from prostate cancer in the screening group was 21% compared with those who did not get screened. Overall, the rate ratio was 0.79 (95% CI 0.68 to 0.91, P=0.001).

In the most recent two years of follow-up, the rate ratio was 0.62 (95% CI 0.45 to 0.85, P=0.003). The relative reduction rose to 29% among men who actually got screened.

Also, the absolute reduction in prostate cancer mortality in the screening group was 0.10 deaths per 1,000 person-years or 1.07 deaths per 1,000 men who were randomized. All told, 6,963 prostate cancers were diagnosed in the screening group for a cumulative incidence of 9.6%, compared with 5,396 in the control group, for a cumulative incidence of 6%.

The authors stated that in order to prevent one death from prostate cancer at 11 years of follow-up, 1,055 men would need to be invited for screening and 37 cancers would need to be detected.

Finally, between the groups, there was no significant difference in all-cause mortality.

Schršder and colleagues concluded that the study results remain consistent with earlier reports but added that "more information on the balance of benefits and adverse effects, as well as the cost-effectiveness of prostate cancer screening is needed."

Despite the conflicting results of the two large trials, it's unlikely that patients in the U.S. will forgo PSA testing in large numbers, according to Manish Vira, MD, of the North Shore-LIJ Health System in Lake Success, N.Y.

"Given that the overwhelming majority of patients believe that screening for cancer is an important component of good health practice, the use of PSA testing is unlikely to diminish," Vira wrote in an email to MedPage Today.

For that reason, he said, "more effort should be made to decrease the burden of overtreatment by increasing the use of active surveillance in men with low-risk prostate cancer."

However, two clear lessons can be learned from the European trial results, he said. First, any potential benefit from PSA screening can probably be obtained from testing every two years, rather than annually.

Second, the benefits of screening, if they exist, probably don't appear until at least 10 years of follow-up, so that "older men with significant comorbidities are unlikely to benefit from screening" and may suffer harm from testing and overtreatment, Vira said.

The researchers did not report external support for the trial. Schršder reported financial links with GlaxoSmithKline and Ferring.

Miller did not report any financial links with industry.

Primary source: New England Journal of Medicine Source reference: Schršder FH, et al "Prostate-cancer mortality at 11 years of follow-up" N Engl J Med 2012; 366: 981-990.

Additional source: New England Journal of Medicine Source reference: Miller AB "New data on prostate-cancer mortality after PSA screening" N Engl J Med 2012; 366: 1047-1048.

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