What is the USPSTF?

I promise I didn’t just randomly string a bunch of letters together. The United States Preventive Services Task Force (USPSTF) is  “an independent group of national experts in prevention and evidence-based medicine that works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services.”  (The definition is from here.) When I was in my residency, we were encouraged to consider this as the standard guidelines that we should follow when practicing medicine.  I find it interesting that many doctors do not follow the guidelines set by the USPSTF.  Just yesterday I had a conversation with a room full of my colleagues about this.  The argument from those who didn’t follow the guidelines was based on a fear of a lawsuit.  Specifically regarding PSA testing.  I plan to write more in detail on the PSA test and prostate cancer screening soon.  The current recommendations from the USPSTF is not to screen for prostate cancer using the PSA test.  They posit that doing the test does more harm than good, and they have a plethora of data to back this up.  My colleagues do agree that checking a PSA carries a high burden of risk for a minimal benefit, but they are afraid that patients will sue them if they get prostate cancer, saying “the doctor never properly screened me,” so they order it.  They say that there isn’t enough time in this insurance-based, fast-paced, health-care delivery environment to really help their patients understand the risks of these tests.  It’s easier to just order the test and move on.  I had another colleague tell me that people just want more testing and they are not savvy enough to understand that more testing isn’t always better, so it’s not worth investing the time.  I hope we can strive for better.  I hope you can ask your providers more questions about why they are ordering the tests they order.

 It can be very confusing when recommendations are seemingly at odds with each other.  Meaning, one professional organization recommends something that the USPSTF says may cause harm.  The PSA test is great illustrator of this.  The USPSTF says never use the PSA to screen for prostate cancer, but the American Urological Association (AUA) says we should discuss the risks and benefits of screening with a PSA in men ages 55-69.  So who should we listen to?

 Most of the time when you really get into the details of the recommendations by each organization, they are saying the same thing with  different ways of wording the final recommendations.  Regarding PSA screening, in the fine print, the USPSTF says it understands that doctors will still order the test and patients will still request it, so they recommend ensuring patients are fully informed about the risks and benefits of screening.   The fine print of the AUA recommendations recognizes the burden of harms associated with screening and the minimal benefit.  There is a similar seeming conflict of recommendations, but overall agreement with breast cancer screening.

 So, why the difference in wording, which can lead to very different interpretations of the same thing.  I think the best answer lies in understanding who is on the panel making the recommendations and what purpose the recommendations serve.

 The USPSTF started in 1984 as a volunteer group of mostly primary care practitioners who would rigorously review the literature and develop guidelines for screening and prevention.  In 1998 the government (the Agency for Healthcare Research and Quality-AHRQ) started supporting the USPSTF, I am assuming out of an understanding of the value of such an organization.  Since then, the recommendations of the USPSTF are reported to Congress to help direct funding to areas where there is need for more research.  The members of the USPSTF are still primary care practitioners (internal medicine, family medicine, geriatrics, pediatrics, behavioral health, obstetrics and gynecology, and nursing).  They are appointed by the director of the AHRQ to serve for 4 years.  They are “screened to ensure that they have no substantial conflicts of interest that could impair the scientific integrity of the Task Force's work.”  Here you can see the names and links to the bios of all the current members.

 Specialty organizations, such as the AUA, are generally groups of practitioners in that specialty.  For the AUA, the recommendations on PSA screening  were formed from review of the literature by urologists.  Some might posit that a urologist is biased in their perception of the value in screening with a PSA.  Both related to their experience in seeing a subset of people who suffer from more severe urological disease and to the financial gains that come from the downstream results of PSA screening.  (Meaning that a positive PSA screen leads to lucrative procedures like biopsies and surgery performed by urologists).

 Personally, I feel most comfortable using the recommendations of the USPSTF to help guide me in the care of patients, but always making sure that the individuals needs are the utmost importance.  For example, even though the recommendation is not to order a PSA screen, I will order this test if someone says they would like the test and they well understand the risks associated with it.

I strongly encourage you to review the USPSTF guidelines before you decide on that next screening test, it might help you to make a more informed decision on the value of the testing.