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Public Health & Policy

Task Force Faces Scrutiny, Controversy

Published: Dec 28, 2012


As part of the Year in Review series, MedPage Today reporters are revisiting major news stories and following up with an analysis of the impact of the original report, as well as subsequent news on the topic. Here's what's happened since we published the first 2012 piece on the United States Preventive Services Task Force (USPSTF) recommendation against PSA testing for prostate cancer in otherwise healthy men on May 21.

Virginia Moyer, MD, laughed out loud at an analogy that the USPSTF is like a parent telling an insistent kid "no," when it makes a recommendation that runs counter to what many physicians support.

"Maybe so," said Moyer, chair of the task force and a pediatrician at Baylor College of Medicine in Houston. "I think probably part of the issue is that people really don't have a good understanding [of the USPSTF], and maybe we're a victim of our own success."

"Way back when the task force got started, prevention wasn't really part of the doctor visit," she explained. "Most physicians weren't very interested in it; it was generally not something that was covered by insurance; and the result was that when people went to see their doctors, prevention was ignored."

Creation of the USPSTF helped change the status of prevention. The task force was charged with giving primary care physicians "good information" about prevention and to make recommendations about preventive services "that actually work."

"That sort of philosophy, of getting prevention that works into the primary care office, seems to have worked extremely well," Moyer said. "The American public now really believes in prevention, to the extent that it is awfully hard to give up things that you think might be working in the way of prevention."

But not all preventive services are beneficial, Moyer pointed out. "Think about it: If you come into your doctor's office for a check up and you feel fine and don't have symptoms, then if the doctor does a screening test, the best thing that can happen to you is that you don't get any worse," she said. "However, all the other things that can happen to you actually make you feel worse."

There needs to be a recognition that prevention and preventive services can come with potential harm, and that harm has to be balanced with potential benefits, she added.

Moyer said the task force has become quite adept at striking that balance, although some observers -- including many physicians -- might argue with that assessment.

USPSTF in the Limelight

Controversy surrounding the PSA decision actually started to roil in 2009, when circumstances created a "perfect storm" for the USPSTF to get a lot of unaccustomed attention.

As Moyer recounted, political debate and bickering about the Affordable Care Act (ACA) had shifted into high gear. In addition, discussion and posturing related to mid-term elections had already begun, and the ACA provision to provide coverage for any service or test that received a grade A or B from the task force focused unprecedented attention on the USPSTF.

"Prior to that time, no one paid attention to the task force," Moyer said. "We often felt like we were toiling in obscurity."

As events unfolded, a recommendation related to mammography screening for women, ages 40 to 49, was the first one out of the gate. The USPSTF recommended that mammography screening be an individual decision between a woman and her physician, as opposed to a mandated exam.

The recommendation set in motion a blizzard of controversy and critical comment that has yet to abate.

Unaccustomed to the media spotlight, task force members were caught off-guard by the reaction to the mammography decision, said Moyer, who was on a 1-year break from the USPSTF at the time. But by the time the PSA recommendation came out, the outcry from supporters of PSA screening was expected.

The push back included the American Urological Association (ASH), which voiced strong opposition to the recommendation, as did individual urologists. William Catalona, MD, a leader in research that led to the development of PSA tests, has been an especially vocal critic.

Though technically not an arm of the government, task force decisions "certainly do carry the weight of the government," said Catalona, of Northwestern University in Chicago. "There is enormous prestige for this to come from a 'US government-appointed agency.'"

The PSA recommendations also drew criticism from medical specialists who noted that the USPSTF does not include physicians from specialties affected by the decisions.

"Not a single person on that panel was a urologist, a radiation oncologist, or a medical oncologist, who commonly treat prostate cancer patients," Catalona said. "This panel really lacked the specialty expertise in the early management of prostate cancer and the treatment of prostate cancer."

Moyer countered that the USPSTF makes "recommendations for preventive services in the primary care setting. All of us are in primary care, so in fact, we are speaking to our peers in primary care."

'We Really Aren't Talking to Urologists'

The panel continues to receive letters and emails concerning the PSA recommendation, some of which question the absence of a urology representative on the PSA panel.

"We really aren't talking to urologists," Moyer said . "Urologists don't see people who don't have any symptoms, who just want to know if they might be at risk for prostate cancer. That's something that happens in the primary care office. Urologists use PSA testing for a variety of reasons, many of which are entirely appropriate, and are something that urologists should be thinking about."

Phoenix-based family physician Doug Campos-Outcalt, MD, who has worked with the USPSTF for several years, seconded Moyer's statements about primary care physicians as the intended audience for recommendations.

"Urologists follow the recommendations of their specialty societies," said Campos-Outcalt, an American Academy of Family Physicians liaison to the USPSTF. "I can't imagine why they would be so interested in recommendations from the task force, unless they're concerned about getting fewer referrals."

Critics of task force decisions also include people who "have made it their life's work to keep people from suffering the disease that their husband or family member died from," Campos-Outcalt continued.

"Whether or not there is evidence that a particular intervention is effective is not something they are particularly interested in, or would know how to evaluate. All they see is that the task force is not recommending it for first-dollar coverage, and that upsets them," he said.

Prevention, Not Deprivation

The bottom line for USPSTF decisions is the extent to which the recommendations influence primary care practice. In that respect, the data have just begun to emerge.

At the Breast Cancer Symposium earlier this year, investigators reported almost a 10% drop in the mammography rate among women, ages 40 to 49, immediately after the USPSTF announced the recommendation. Thereafter, mammography rates in that age group stabilized, but 2 years later remained 5% lower than the rates prior to the recommendation.

Regarding the PSA decision, influence on PSA testing rates has yet to be documented in published studies, but the evidence "is out there and PSA testing has decreased," said Catalona. "I hear from patients who are in HMOs or similar healthcare organizations, and when they go to their doctors, their doctors say 'We don't do PSA testing anymore. Word has come down from on high that we're not supposed to order PSA tests anymore.'"

"I think there really has been a substantial reduction in PSA testing," he added.

Catalona has seen a draft recommendation to end PSA screening tests in the Veterans Affairs Health System. He shared an email from a colleague who said house staff at one VA center had been instructed to stop ordering routine PSA tests and to delete any pending orders for tests.

Looking ahead to decisions not yet reached, Moyer expressed a desire for better understanding about the task force and its responsibilities.

"We are a group of primary care providers," she said. "We are experts in prevention, experts in understanding scientific literature. Our sole purpose is to improve the health of Americans. We are not out to save money, because improving health often costs money, but health is worth it."

When the task force makes a recommendation against a procedure or test, their goal is not to deprive the public, she emphasized. "It's because the science says that doing that thing is more likely to result in harm than benefit, and we don't wish to harm the American public."

Charles Bankhead

Staff Writer

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