AUA pushes for USPSTF reform, coverage for PSA

Washington-Two years ago in May, the U.S. Preventive Services Task Force (USPSTF) recommended against PSA-based screening for prostate cancer, asserting that “many men are harmed as a result of prostate cancer screening and few, if any, benefit.”

The Task Force said PSA tests should not be used regardless of risk and gave PSA-based screening a grade of “D.”

The Task Force and its stance on prostate cancer screening were back in the news this spring, when a commissioner of the Medicare Payment Advisory Commission (MedPAC) questioned the benefit and cost of screening and the cost of resulting “unnecessary” treatments.

In 2012, when the Task Force issued its recommendation, USPSTF co-chair Michael LeFevre, MD, made this comment: “Prostate cancer is a serious health problem that affects thousands of men and their families. But before getting a PSA test, all men deserve to know what the science tells us about PSA screening: There is a very small potential benefit and significant potential harms.”

Dr. LeFevre went on to encourage clinicians “to consider this evidence and not screen their patients with a PSA test unless the individual being screened understands what is known about PSA screening and makes the personal decision that even a small possibility of benefit outweighs the known risk of harms.”

That development, of course, set off alarms within the urology community and the following May the AUA issued its guidelines on prostate cancer screening, which state that, in men ages 55 to 69 years, the decision to undergo PSA screening involves weighing its benefits against potential harms. Shared decision making is recommended.

AUA throws support behind USPSTF reform

The recommendation prompted the AUA to support the USPSTF Transparency and Accountability Act, sponsored by Reps. Marsha Blackburn (R-TN) and John Barrow (D-GA). That measure, H.R. 2143, would require the USPSTF to:

• publish research plans to guide its systematic review of evidence and new science relating to the effectiveness of preventive services

• make available reports on such evidence and recommendations for public comment

• codify the grading system used so it cannot be changed without an appropriate review

• establish a preventive services stakeholders board to advise it on developing, updating, publishing, and disseminating evidence-based recommendations on the use of clinical preventive services.
   

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In addition, the bill would ensure that Medicare or other payers cannot deny payment for a preventive service solely based on the Task Force grade.

That final point is especially important and was emphasized in a discussion during the March 6 meeting of the Medicare Payment Advisory Commission (MedPAC), which provides guidance and recommendations to Congress on Medicare payment policy.

During that discussion, MedPAC commissioners asked why Medicare continues to pay for services not recommended by the USPSTF, including PSA screening.

Commissioner Rita Redberg, MD, MSc, noted that USPSTF had recommended against PSA screening, but that Medicare continues to cover it.

“But it’s not just the cost of the screening,” she commented. “It’s the cost of all of the treatment that has not been shown to extend life for men from the PSA screening. And so you have men getting unnecessary surgeries that lead to impotence and urinary incontinence, and men getting chemotherapy, and then men getting proton beam and IMRT, and at incredibly high rates.”

She pointed out that “people are now investing in buying proton beam therapy units for their hospitals because Medicare is paying very generously for this even though it hasn’t been shown to be more effective than even watchful waiting-essentially, not doing anything.”

Dr. Redberg went on to say that MedPAC’s responsibility is to align payment policy with the best evidence.

“If people choose to have low-value procedures, I think that should be their choice, but it should not be Medicare’s responsibility to pay or pay more for things that are not of higher value.”

AUA letter: Focus on educating PCPs

As a result of those comments, the AUA fired off a letter in April to MedPAC Chairman Glenn M. Hackbarth, JD, MA, stating:

“The AUA feels strongly that any attempt to broadly reduce access to PSA testing would be a disservice to men, especially those with risk factors for prostate cancer (such as African American race or positive family history). Instead of instructing primary care physicians to discourage men from having a PSA test, the Task Force should focus on how best to educate primary care physicians regarding targeted screening and how to counsel patients about their prostate cancer risk. The decision to use or to forego the PSA test is a choice that should be individualized, made by informed patients in conjunction with their providers.”

Then, in May, William F. Gee, MD, AUA 2014-‘15 president elect, attended a political event, where Barrow spoke highly of the AUA and the association’s political action committee, UROPAC. Barrow is a prostate cancer survivor who credits urologists with saving his life.

The AUA, in a May 20 Policy & Advocacy Brief, said it continues to work with Barrow’s legislative staff on the USPSTF bill and that UROPAC supports him financially.

Dr. Gee also attended a fundraiser for Rep. John Fleming, MD (R-LA), and discussed several of the AUA’s priorities, including access to PSA screening and the USPSTF legislation, of which Dr. Fleming is a co-sponsor. Dr. Fleming made the comment during the meeting that historically physicians only needed to worry about caring for their patients, but now they need to care about what Congress is doing as well.UT

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