publication date: May. 11, 2018

Trials & Tribulations

The imaginary interview

(with apologies to Molière, aka Jean-Baptiste Poquelin)

Derek Raghavan1

By Derek Raghavan

President, Levine Cancer Institute, Carolinas HealthCare System

 

As I read the latest offering from the US Preventive Services Task Force, this time another encyclical on prostate screening, I felt a recurrence of the extreme irritation left over from the last time they wasted my (and their) time. Borrowing from Molière’s “The Imaginary Invalid”, I conceived an Imaginary Interview with an un-named representative of this band of bozo’s that seem to have few boundaries, a high level of comfort in wasting taxpayer dollars and editorial space, and who seem set on providing useless homilies that, at best, provide no value. This is couched as a Paul Goldberg-style low-key interview… and so the play begins:


Act I:

The Cancer Letter Interviewer (CL) enters, and greets USPSTF representative (PR)

 

CL:

“Good morning, I appreciate your time. I have a few questions.”

PR:

Great…happy to have another chance at wasting time.

 

CL:

You have written several papers on PSA and prostate screening, in addition to your famous paper on testicular cancer screening and the one on timing of mammography. It seems that they have created more confusion than anything else. Why do you do it?

PR:

Because we are experts and really good at recycling data, doing meta-analyses, and expressing opinions on stuff.

 

CL:

Have you actually done your own research on the topics that you write about?

PR:

Mostly we haven’t…we really don’t have time because of our meetings and analytical work.

 

CL:

Let’s cover the topics that I have mentioned. We’ll start with testis cancer screening. You wrote a position paper in Annals of Internal Medicine on this important topic. What was the key point?

PR:

Basically we reviewed, in careful detail, the absence of data to recommend or not recommend testis screening or self-examination.

 

CL:

Sort of a “yes, we have no bananas” paper?

PR:

That’s mean.

 

CL:

Did you use the bully pulpit to educate clinicians or the public on the importance of young men being aware of testis cancer, how it presents or the associations with risk factors (like testicular maldescent and association with atypical nevi)?

PR:

Good idea!! No we didn’t do that, but you’ve given me an idea for another paper.

 

CL:

What about your work on the timing of mammography? Your critics have implied that the data were weak, have been widely challenged, and that effectively you might have discouraged women from undergoing mammography as it seemed that the breast screening groups didn’t really know how to do it well, nor when to do it.

PR:

Yeah, that’s hurtful. We did the best we could. There is no doubt that there is controversy about timing of mammography, and we felt it important to make our own statement.

 

CL:

So some years after that publication, do you feel that you have really advanced our understanding of this important topic?

PR:

Possibly not, but we did something really good—we called for more research!!

 

CL:

OK. Let’s shift to the issue of PSA and prostate screening. What are the key take-aways from your recent publication in JAMA?

PR:

The most important take-away is that we got the editors of JAMA to take our paper. That’s pretty cool isn’t it? It’s a great journal and shows how important we really are!!! We used to publish in Annals of Internal Medicine, but folks became confused between the different Annals papers, so we felt our impact was being reduced…and surgeons mostly don’t read that publication anyway. But, back to your question, our key points were:

For men over the age of 69 years, you really shouldn’t do prostate screening. We call that a D recommendation.

For men between 55-69 years of age, it’s really up to the patient and the doctor, and they should have a conversation about it because we have done lots of repeat analyses of the published data and we think it probably doesn’t have a big impact, but it might have a small impact…but we really aren’t sure…so we said more research should be done. The key issue for this group, and it’s a really cool new idea, is that we propose the novel concept that doctors should discuss treatment with patients. Of course, the down side is that takes time, and might add to expense. Because we are purists, we NEVER talk about expense.

 

CL:

Seems to me that perhaps you should think about the fiscal issues…they are increasingly governing health policy, and the IOM has really focused on its Choosing Wisely Campaign.

PR:

Oh no! If we did that, patients would accuse us of bad stuff, and we can’t take that sort of heat. We know exactly how much it costs per screening visit, including clinician time, the costs of the PSA assays, time lost from work, and the number of patients who are screened initially each year, and then triaged into active surveillance programs or the more conservative watchful waiting, and we know the very small return on investment when one looks as morbidity, mortality and numbers of dangerous cases diagnosed. But we could never make a statement about that!!! Remember the experience in Oregon…we’d be criticized for putting cost over life.

 

CL:

Perhaps I’m missing the point… isn’t it true that most studies, including the recent PROTECT trial from the UK, have shown that there really is only a small impact on lives saved from prostate cancer deaths (actually NO impact in PROTECT), and nobody has ever shown an impact on overall survival (unlike the studies in breast cancer and lung cancer)?

PR:

We never talk about overall survival…several of our group believe that overall survival doesn’t really matter and is heavily confounded by other stuff…so we just prefer not to mention it…same thing for cost.


ACT II:

 

CL:

This is very informative indeed. The bottom line is that the evidence to support routine PSA screening is pretty slim, there is a strong counter-movement that focuses on investigation of symptomatic patients (which isn’t screening), the identification of occasional patients with high grade, dangerous prostate cancers early in their natural history, and many of them are cured…but many are not, and we also accidentally may over-treat a bunch of older men with low grade tumors and cause morbidity and anxiety. The vast majority of men identified by this screening exercise actually become Molière’s “Imaginary Invalids” as they are really fearful of having cancer, and don’t know what is their safest course. By the way, the Europeans have actually suggested that survival is WORSE in the men over the age of 69, right?

PR:

Yup… and that’s why we said don’t do it in old guys.

 

CL:

But you were less definitive in the younger population, and didn’t say anything about men in the 45-55 age group.

PR:

Yeah…we didn’t know what to say, and we already had another paper in the hopper with JAMA, so we just left it at that.

 

CL:

Final question—in your 2012 paper, you made pretty strong general statements, which de facto included men with a family history and African Americans. Now you have reversed that view—are there extensive new data to support your opinions.

PR:

Actually no. But we did some data dredging to find supporting information that was already “out there”, and we realized that we goofed in failing to comment on family history and African American race and risk factors…so, we pretended that it was brand new information. Pretty good, huh?

 

CL:

So now what?

PR:

Well, we’re struck by another cool opportunity…low-dose CT screening for lung cancer. Not the strongest evidence, so we’ll re-analyze that and we should be able to find a good journal in which to express our opinion.

Do you know the phone number of the NEJM editor by any chance?

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