Our Greatest Wealth Is Health

Andrew Siegel MD   5/20/2023

USPSTF = United States Preventive Services Task Force

“To improve the health of the nation, focused on preventive services” is the noble intention of the USPSTF, first created almost 40 years ago.  This circle of “experts” in preventive and evidence-based medicine provides recommendations regarding screening for diseases, wield a great deal of power and influence and have a profound effect on clinical practice guidelines and reimbursement.   

The USPSTF consists of 16 volunteers who have backgrounds that include the following disciplines: internal medicine, family medicine, pediatrics, behavioral health, obstetrics/gynecology, and nursing.

Over the past four decades, the USPSTF has made many recommendations — some prudent, but a fair share that were unfounded and flawed, to the absolute detriment of the public’s health.  The intention of today’s entry is to review a few of their “grave” errors with regard to screening for prostate, testes, and skin cancer. Last week’s entry reviewed the disservice of the USPSTF to American women concerning screening for breast cancer.

Screening for prostate cancer is of vital importance since prostate cancer — the most common cancer in men (aside from skin cancer) — is a “silent” cancer that causes no symptoms that would provide clues to its occurrence early on in its course.  DRE (digital rectal examination) and PSA (prostate specific antigen) blood testing are the two key means of screening for prostate cancer.  The intent of screening is to identify men with aggressive, or potentially aggressive, localized prostate cancer that can be successfully treated to prevent the morbidity and mortality associated with advanced or metastatic prostate cancer.

Prostate cancer screening with PSA has been the subject of intense controversy and debate.  A major backlash against prostate cancer screening occurred in 2012 when the USPSTF gave PSA screening a grade “D” and called for the total abandonment of the test.  They counseled against the use of PSA testing in healthy men, postulating that the test does not save lives and leads to more tests and treatments that needlessly cause pain, incontinence, and erectile dysfunction. Furthermore, the USPSTF recommended against the DRE, stating: “The use of the digital rectal exam as a screening modality is not recommended because there is lack of evidence of a benefit.” 

Of note, there was not a single urologist on the committee.  The same organization had previously advised that women in their 40s not undergo routine mammography, setting off another blaze of controversy.  Uncertainty in the lay press prompted both patients and physicians to question PSA testing and recommendations for prostate biopsy. 

Unfortunately, the 2012 USPSTF recommendation essentially resulted in the abandonment of prostate cancer screening by primary care physicians and years later there has been an upsurge of men with higher PSA levels, more aggressive prostate cancer, more advanced prostate cancer, and increased prostate cancer mortality.

In 2018, the USPSTF reversed their stance (as they recently did for breast cancer screening) and revised their recommendation for prostate cancer screening, giving PSA testing a grade “C” recommendation (offering the test selectively, based on professional judgment and patient preferences) to men ages 55 to 69.  They recommended against testing men older than 70.

In my humble opinion

Is there really any harm in screening?  While there are potential side effects from prostate biopsy (although they are rare) and there are certainly potential side effects with treatment, there are no side effects from drawing a small amount of blood and certainly not from a DRE.

PSA is an important part of a comprehensive approach to early prostate cancer detection.  Marginalizing this important test does a great disservice to patients who may benefit from early prostate cancer detection.  PSA is not only the best early cancer detection test in urology, but arguably may be the best early cancer detection test in all disciplines of medicine.

Overall, PSA screening has resulted in detecting prostate cancer at earlier and at more curable stages, often before it has a chance to spread and potentially become incurable.  PSA screening led to a 4% annual decline in metastatic prostate cancer and death from 1992 until recent years, when an uptick in advanced prostate cancer and death rates occurred—attributed to the near abandonment of PSA testing based upon the mistaken recommendations of the USPSTF. 

I have practiced urology in both the pre-PSA and the post-PSA era.  In my early career (pre-PSA era), it was not uncommon to be called to the emergency room to consult on men who could not urinate (prostate cancer resulting in obstruction to urine outflow), who were found to have rock-hard prostate glands (classic exam of advanced prostate cancer) on DRE, and imaging studies that showed diffuse spread of prostate cancer to their bones—metastatic prostate cancer with a grim prognosis.  In the 1980s, about 20% of patients with prostate cancer presented with metastatic disease.  Fortunately, in the current era, only a small percentage of men present with metastatic disease because of PSA screening.

The bottom line is that with respect to prostate cancer screening the USPSTF screwed up bigtime, resulting in needless morbidity and mortality and a generation of primary care physicians many of whom have abandoned the prostate. This parallels how they mishandled the breast cancer screening situation.

2022 American Cancer Society USA prostate cancer statistics: New cases: 268,490, accounting for 27% of all new cancer cases in men.  Deaths: 34,500, accounting for 11% of cancer deaths in men.

Estimated new cases 2023: 288,300.

Do you really not want to screen for this disease?

TESTES CANCER SCREENING

Testes cancer screening refers to testes self-exam or a clinical exam by a physician.  The USPSTF recommends against routine screening for testes cancer in adolescent and adult males, giving testes cancer screening a “D” recommendation, concluding that the harms of screening outweigh the benefits.  Their logic is that testes cancer is relatively rare and has favorable outcomes with treatment and that there is minimal evidence to assess the accuracy, yield, or benefits of screening.  They state that there is no evidence that teaching young men how to examine their testes would improve health outcomes.

In my humble opinion

Most testes cancers are discovered by their patients or partners.  Is that not telling enough?  The goal of testes self-exam is to find a cancer – in an early and treatable stage – at a time when it is localized and has not spread to the lymph nodes or lungs, which are common sites of metastasis.

Because sperm production requires that testes are kept cooler than core temperature, nature has conveniently designed men with testicles dangling from their mid-sections. There are no organs in the body—save female breasts—that are more external and easily accessible to examination. One of the great advantages of having one’s gonads located in such an accessible locale—conveniently “wrapped” in the scrotal satchel—is that it makes them so easy to examine. This is as opposed to the ovaries, which are internal and not amenable to ready inspection. This explains why early testes cancer diagnosis is readily made, as opposed to ovarian cancer, which most often presents at a more advanced stage, because of the inaccessibility of the ovaries.

The bottom line is that the USPSTF recommendation is ludicrous.  What harm is there in self-examination or a physician examining the testes?  By all means, let’s take advantage of the physical examination of organs that are accessible…If only the pancreas was readily accessible to exam! Teaching self-exam makes total sense and every year I see a few patients who self-detected their own cancer, had their cancer detected by their partner, or had their cancer diagnosed by their primary care physicians. Furthermore, periodically I diagnose at least several incidental testes cancers in men seen in the office for unrelated reasons. The USPSTF logic that screening should be avoided since even advanced testes cancers generally fare well with treatment is seriously flawed, since early diagnosis is always prudent.

2022 statistics: Testes cancer new cases USA: 9190, accounting for 0.9% of all new cancer cases in men.

Testes cancer deaths USA: 470, accounting for 0.15% of cancer deaths in men.

SKIN CANCER SCREENING

Skin cancer is the most prevalent cancer in the USA.  Basal cell and squamous cell cancers are common but rarely cause mortality, as opposed to melanomas that are responsible for only about 1% of all skin cancers but cause the most frequent number of deaths from skin cancer.

A visual skin exam is the most common method of appraisal of the skin, seeking the presence of lesions.  This can be performed with the naked eye, magnification, or with serial total body imaging.  Suspicious lesions mandate biopsies.

The USPSTF has given screening for skin cancer an “I” rating, meaning that there is insufficient evidence and the balance of benefits and harms cannot be determined.  They state that potential harms that may accrue from screening include scarring from biopsies, psychosocial harms (anxiety and worry) from screening, and overdiagnosis leading to overtreatment.

In my humble opinion

How else are you possibly going to diagnosis a skin lesion without careful visual inspection?  The key word is “visual”…a visually impaired person cannot discover a skin lesion and who better than a dermatologist for this task. 

According to the American Cancer Society and the American Society of Clinical Oncologists, an estimated 3.4 million Americans were diagnosed with skin cancer in 2022, 100,000 of which were melanoma with an estimated 7650 deaths from melanoma.

My final thoughts about the USPSTF:

• If the USPSTF is going to make recommendations involving organ systems in which there exist medical specialists who focus and specialize on that organ system, those appropriate specialists must be represented on the task force, i.e., urology, dermatology, and oncology in the aforementioned situations.
• The USPSTF seems to have a thing against physical examination, i.e., the prostate, the testes, and the skin in the aforementioned situations.   A physical exam generally includes observation, palpation, percussion, and auscultation and I remain clueless why the USPSTF aims to marginalize physical examination, the most fundamental tool of physicians.
• The USPSTF has issued other dubious recommendations for other cancers; I just picked three for the sake of this entry but please visit their website if you are interested: USPSTF
• The USPSTF wields way too much power and influence! It has been my experience that many primary care physicians follow their recommendations as if it were the gospel.
• “Ivory tower” academic recommendations do not always fly well in the trenches of the medical clinics where practical and commonsensical, no nonsense, prudent guidance is a necessity.
• The USPSTF guidelines beg the question as to if they are “in bed” with the insurance companies.
• A consistent USPSTF concept that results in a poor grade is that screening for any given cancer does not necessarily reduce mortality from that cancer.  But is reduction in mortality always the point of screening?  How about reduction in morbidity and maintenance of quality of life? Just because a basal cell skin cancer or squamous cell cancer doesn’t kill you, is that a reason not to screen for it?

Bottom Line: The great irony is that while the intention of the United States Preventive Services Task Force is to improve the health of the nation by setting guidelines regarding screening and detecting cancers early on in their natural course, they have actually functioned to “prevent services,” hindering physicians from performing and ordering necessary and appropriate diagnostic tests and doing a disservice to the collective health, wellness, and longevity of the nation.

Wishing you the best of health,

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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, one of the largest urology practices in the United States.  He is the co-founder of PelvicRx and Private Gym.  His latest book is Prostate Cancer 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families. 

Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

PROSTATE CANCER 20/20 is now available at Audible, iTunes and Amazon as an audiobook read by the author (just over 6 hours). 

Dr. Siegel’s other books:

THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health

Video on THE KEGEL FIX

MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health