Response: Re: The Prevalence of Low-Value Prostate Cancer Screening in Primary Care Clinics: A Study Using the National Ambulatory Medical Care Survey

To the Editor: We have read Dr. Takahashi’s letter and appreciate the invitation to respond. We also thank Dr. Takahashi for the thoughtful letter and observations. We agree with Dr. Takahashi’s overall concern about the known harms associated with PSA screening. However, we believe the letter illustrates some common misconceptions regarding the United States Preventive Services Task Force (USPSTF) Grade definitions and practice implications, and below we attempt to correct some of these.

First, Dr. Takahashi states a USPSTF C Grade indicates “insufficient level of certainty of evidence that the benefits outweigh the harms.” In fact, the Task Force issues an “I Statement” (rather than a C Grade) when it finds that “current evidence is insufficient to assess the balance of benefits and harms of the service.”¹ Second, Dr. Takahashi states a Grade C means “the service cannot be recommended.” In fact, for Grade C recommendations, the Task Force’s suggestion for practice is to “offer or provide this service for selected patients depending on individual circumstances.” In the case of PSA screening, the 2018 Task Force recommendation states that

“In determining whether this service is appropriate in individual cases, patients and clinicians should consider the balance of benefits and harms on the basis of family history, race/ethnicity, comorbid medical conditions, patient values about the benefits and harms of screening and treatment-specific outcomes, and other health needs.”

Research has shown that prostate cancer screening is a highly preference-sensitive decision and that many men prefer to receive screening, even when informed of potential harms.² Third, although Takahashi is correct that the Task Force recommends clinicians discourage routine screening in men 70 years and older, the blanket statement that “Grade D means that the service should not be performed because it will cause harm to the subject” oversimplifies the issue when it comes to caring for individual patients. The USPSTF statement is more nuanced and allows for individualized decision making:

“Harms are greater for men 70 years and older. In determining whether this service is appropriate in individual cases, patients and clinicians should consider the balance of benefits and harms…Clinicians should not screen men who do not express a preference for screening and should not routinely screen men 70 years and older.”³

Other organizations that issue screening recommendations, such as the American Urologic Association (AUA) also leave room for individualized decision making. The AUA early prostate cancer detection guidelines recommend that men over the age of 70 not be routinely screened for prostate cancer,⁴ but also state that men who are 70 years and older who are in excellent health may benefit from prostate cancer screening. In practice at the individual patient level, clinicians must use their judgment and use shared decision making with their older patients about prostate cancer screening so that the patient can make the decision that is right for them.^3,4

Finally, although we share Dr. Takahashi’s view that screening men with PSA without discussing benefits and harms or elicitation of patient preferences is not ethical, we disagree that public insurance coverage of PSA screening “violates the Declaration of Helsinki.” Moreover, the suggestion that public insurers, such as Medicare or the Veterans Health Administration, should stop covering cover PSA screening is impractical on many accounts, including that these US public insurers cover many services for which there is uncertainty regarding net benefit.

In conclusion, our study found substantial use of prostate cancer screening tests in men 70 years and older, and we agree that this generally reflects low value care. However, there are also complexities that involve risk factors, comorbidities, and preferences that determine the appropriateness of prostate cancer screening in the care of individual patients, including those 70 years and older. There are some men who might benefit whereas most men may not. We should not forget that medicine is a profession in which professional judgment is paramount to ensure that patients receive the best possible care that aligns with their preferences. Such judgment is created by the clinician’s past experiences and their knowledge of the specific patient.