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Physicians Seeking Middle Ground in Prostate Screening Debate

Joe Cantlupe, for HealthLeaders Media, November 3, 2011

For two decades, Michael Barry, MD, has struggled with the question of whether men should be screened for prostate cancer. Barry hoped the U.S. Preventive Services Task Force (USPSTF) would settle the long-running debate. But when the task force issued a draft recommendation last month against screening, Barry abandoned his hope for a definitive answer—primarily based on the use of one qualifying word: "small."

Barry, president of the Foundation for Informed Medical Decision Making calls the controversy over prostate-specific antigen (PSA)–based screening and treatment of screening-detected prostate cancer an argument that "refuses to die."

Although 20 million men undergo the screening each year, the task force insists that it isn't generally necessary. In October, the USPSTF set off the latest round of debate with this conclusion from its draft report: "Prostate-specific antigen–based screening results in small or no reduction in prostate cancer–specific mortality and is associated with harms related to subsequent evaluation and treatments, some of which may be unnecessary."

For men aged 50 to 69, "the evidence is convincing that the reduction of prostate cancer mortality 10 years after screening is small to none," according to the task force. "The evidence is convincing that for men aged 70 years and older, screening has no mortality benefit."

In making its findings, the task force last month referred to two several clinical trials, and noting that neither trial some showed no decrease in overall mortality with the use of PSA-based screening through 11 years of follow-up, and that all trials showed either a "small or no benefit" in prostate cancer–specific mortality, Barry wrote last month in the New England Journal of Medicine.

It's the word "small" that gets him, Barry says.

"Who is to decide what constitutes a 'small' benefit and whether it outweighs the potential harms?" Barry he asks.

"Weighing the pros and cons to make a decision about PSA screening is an individual process, and different well-informed men will make different decisions," Barry told HealthLeaders Media. Yet the task force's recommendation "removes the patient from the equation and puts the physician in the central position of discouraging use of the test."

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