Money Makes Its Voice Heard
The relative quiet following the changes to cervical cancer screening recommendations may also reflect the numbers. Only about 12,000 new cases of cervical cancer are diagnosed annually, compared with 214,633 new cases of prostate cancer in 2008, the most recent year for which numbers are available. Similarly, mammograms were ordered or provided in 20.3 million physician office visits and 2.3 million hospital outpatient department visits in 2009 alone.
The financial stakes are high in prostate and breast cancer and the rhetoric proportionate.
The American Urological Association expressed outrage after the release of the UPSTF PSA recommendation, warning that it could potentially turn back the clock to a time before PSA testing when "men presented with high-grade, metastatic disease for which there was little or no treatment beyond palliative care."
Dr. Otis Brawley, chief medical officer of the American Cancer Society, defended the USPSTF in a recent commentary, saying that unlike many of their critics, USPSTF members are ideally suited to assess the science objectively because they have no "emotional, ideological, or financial conflicts of interest" and understand the complicated science of screening.
He also expressed hope that the new PSA recommendations will end mass screenings, a "lucrative business" that offers tests outside the physician-patient relationship, often in shopping malls and parking lots with sponsorship from hospitals, medical practices, and even an adult diaper company.
For his part, Dr. Richard Albin, who discovered PSA, has been quoted as saying, "I never dreamed that my discovery 4 decades ago would lead to such a profit-driven public health disaster."
Some urologists have criticized the USPSTF for failing to include urologists on the panel and for the absence of a cost analysis.
"If you’re not saving any lives, then any money you’re spending is wasted, and you don’t need a complicated cost-effectiveness analysis to figure that out," countered Dr. Moyer.
Physicians and patients, however, may need a scorecard to wade through the rhetoric and conflicting data, frequently cherry-picked to argue for or against a particular screening test. In a recent study, 30% of women reported that the 2009 USPSTF mammography guidelines confused more than they helped them understand when to get a mammogram (Am. J. Prev. Med. 2011;40:497-504)
A More Nuanced Conversation
There’s little doubt that the task force’s recent decisions will dramatically reshape mammography and PSA screening in the United States, but the question is by how much.
"Largely what we’ve communicated is all the benefit, but I think the U.S. Preventive Services Task Force is communicating all the harms. And the right place is somewhere in between," Dr. Therese Bartholomew Bevers, medical director of the Cancer Prevention Center at the University of Texas M.D. Anderson Cancer Center in Houston, said in an interview.