When failing institutions complain about losing support and funding

The United States Preventive Services Task Force.

The United States Preventive Services Task Force issues recommendations for exactly that. For prostate cancer screening they say it's up to you. For mammography they say every other year over the age of 40. For colon cancer screening they say colonoscopy or fit or annual fecal DNA. For depression and anxiety, they recommend screening for these maladies.

Is any of this evidence-based?

Prostate cancer screening: The evidence is clear. It does not improve all-cause mortality, and people dispute if there is a prostate cancer-specific reduction. It has serious side effects including impotence.

The USPSTF says it's up to you. That's a coward’s compromise. A few years ago they said don't do it, but they got too much lobbying pressure and had to cave.

Even the compromise position could have evidence, but doesn't. You could imagine a randomized study that compares no screening, to screening, to the choice is up to you. We could measure prostate cancer outcomes and patient satisfaction outcomes. That trial doesn't exist. The USPSTF tries to resolve a custody battle by cutting the baby in half.

With mammography, the trials are old and obsolete. There is no all-cause mortality reduction. There was a breast specific mortality reduction, but this was present only in trials with sub-optimal randomization AKA problematic trials. And whether or not any of this data has bearing in the modern world is unknown. Again, the USPSTF lands in a spot that is just make-believe. Every other year? Where did they get that? A modeling exercise.

With colon cancer screening the USPSTF embodies a philosophy of any screening is better than no screening and recommends a variety— keep all stakeholders slightly unhappy. But again, there's no evidence that this is better than just offering the one screening with the best data: flex sig. And the evidence is for over 50, but they recommend over 45. They literally pulled the 45 number… for lack of a better expression… out of their ass.

In all these examples, the USPSTF is like a mediator. It's crafting a compromise to keep everyone mildly unhappy. And just like a mediator, it's ultimately arbitrary. Calling this evidence-based is untrue.

If a doctor wants to treat a healthy person with platinum chemotherapy, the evidence-based answer is no. Not: fine, but just give him it every 4 weeks rather than every two (USPSTF B recommendation). Or discuss with your doctor and make the choice right for you. (USPSTF C recommendation)

With depression and anxiety screening, the USPSTF is just doing the feel good thing, lacking direct randomized evidence altogether. A cynic would say they just want to get more people to take ssris. I would laugh if I heard that, but I would have difficulty rebutting it.

It's against this backdrop that two papers appear this week, one in JAMA and one in the New England Journal of Medicine complaining about the USPSTF being put on ice by Robert Kennedy.

It's funny that we have two papers with non-overlapping authors complaining about the same thing. Never miss an opportunity to add a line to your CV.

The USPSTF authors can't even agree to write a joint complaint document. We agree to complain about Bobby Kennedy every 2 months starting at the age of 35.

Obamacare ties coverage decisions to the uspstf, which has ironically made the group more subject to lobbying pressure. The recommendations the group issues would otherwise be worth nothing. There is no proof that the USPSTF has arrived at the optimal solution. There is no ongoing study of whether or not they are solution is the best solution.

What they're doing is not evidence-based medicine. It's trying to craft a one-size-fits-all solution in spaces where the evidence is ambiguous, lacking, disputed, debated, or tendentious. It's being pulled in one direction by the radiologist, in the other direction by the family Medicine doctor, in the other direction by the surgeon, and in another direction by the makers of ssris and 3D mammogram machines.

Now, it's been basically shut down.

I miss them as much as I miss a colonoscopy.

I think the people on the uspstf are stuck in their own bubble. No one has told them that what they're doing is… sorry to be the one to say… a bad job. They are failing to issue evidence-based solutions against vested interests and they are settling on compromised positions that sate no one: neither the evidence-based purist, nor the companies and doctors making money from the services.

Why do we need taxpayer money to pay for this?

I've been puzzled with failing institutions complaining that they are losing their funding. The CDC told us we need to stand 6 ft apart, put cloth masks on our children as young as 2, and put out a steady stream of MMWR propaganda to support these positions. Why are they then surprised that they're being carved up?

The problem with evidence-based public health, and evidence-based preventive medicine is that it's difficult. In most cases we don't have great evidence. What we should be doing is running very large, publicly funded randomized studies.

The USPSTF's recommendation on PSA screening should be only in the context of a randomized study with a control arm of nothing. But they don't have the courage to do that.

The JAMA study laments the possibility that without the USPSTF, the specialty organizations will drive the show. Amazing insight. Next, you'll tell me that the pharmaceutical industry drives the clinical trials agenda. Or that the sun rises in the East.

Of course, modern medicine is nothing more than a game of hungry, hungry hippos where every specialty organization to trying to gobble up the most marbles. But creating a federally funded task force that's supposed to be impartial and evidence-based and telling every hippo they can eat two marbles, while failing to generate the evidence that the hippos actually need or deserve any marbles that's not a terrific solution.

I'm surprised that they're surprised. Universities, the USPSTF, the CDC- these are failing institutions. They've leaned into controversial spaces and made definitive proclamations. They're just going to get further eroded and broken in the decades to come. A JAMA viewpoint and a competing NEJM perspective are not going to save them, and ironically reflect the pettiness of academic publishing.

The United States government no longer needs a USPSTF (D recommendation - harms>benefits). This determination was reached after years of falling short.