I am a Urological Oncologist at tertiary referral center who appreciates the concerns of overdiagnosis and overtreatment of prostate cancer. Although my main academic interests lie outside the prostate cancer space, I have written on the topic of screening, specifically highlighting the issues of inappropriate PSA screening in patient populations that are unlikely to benefit:

http://www.ncbi.nlm.nih.gov/pubmed/23795784
http://www.ncbi.nlm.nih.gov/pubmed/25205302

Indeed, opportunities for more effective screening certainly exist.

Nevertheless, compelling data suggest that screening has moved the needle on reducing incidence of metastatic disease at presentation and prostate cancer mortality. In a recent NEJM editorial, even H. Gilbert Welch, a champion against overdiagnosis, admits that PSA screening is not a black and white issue. Before making your decision regarding this issue, this editorial is worth a read:

http://www.nejm.org/doi/ref/10.1056/NEJMp1510443#t=article

As such, the proposed measure to disincentivize PSA screening through financial penalties is not justified. It appears that the spirit of this effort is based on the USPSTF recommendations; however, it is important to note that these guidelines are hotly debated.

In fact, it is my understanding that the USPSTF is now seeking public comment for potential revision of its initial guidelines. For completeness, I will list the most commonly provided reasons that underscore weaknesses of the USPSTF recommendation (adopted from Journal of Clinical Oncology Vol 30(21) p2581):

• Definitive conclusions based on incomplete data– Interim analysis at only 9 years of follow-up was used for ERSPC trial– 2 additional years of follow-up of ERSPC demonstrated definitive reduction in PCSM in screening arm (relative risk, 0.79; 95%CI, 0.68 to 0.91; P<.001)

• Overall mortality misleading as an outcome measure for screening, since other cause mortality drowns out PCSM outcomes.

• PLCO trial highly flawed (over 50% of control arm had PSA screening) and should not have been used as part of USPSTF recommendation

• Prostatectomy risks overestimated – 0.5% mortality data reflects 20-year old Medicare data. Actual mortality rates closer to 0.1%

In summary, as a Urologic Oncologist who believes PSA is overused and prostate cancer is often overtreated, I firmly believe that penalizing physicians for PSA screening throws out the proverbial baby with the bath water.

I hope that the screening debate and screening policies can be decided using less drastic measures than the one proposed.