PSA testing utilization decreased by 50% among primary care physicians at Oregon Health & Science University, following a recommendation against screening from the USPSTF.
Ryan Werntz, MD
PSA testing utilization decreased by 50% among primary care physicians at Oregon Health & Science University, following a recommendation against screening from the United States Preventive Services Task Force (USPSTF). In particular, the most significant decrease in PSA use was seen in men aged 50 to 70 yearsa cohort most likely to benefit from screening, according to data presenting at the 2015 American Urological Association (AUA) Annual Meeting by Ryan Werntz, MD.
“If you look back before PSA was a big part of prostate cancer screening, 20% to 25% of men would often first see a physician with back pain and be subsequently diagnosed with metastatic disease,” said Werntz, a urologic resident at OHSU. “It’s a little bit unnerving, because if the guidelines for primary care physicians are recommending not to screen for prostate cancer, we could go back to those days when 1 in 5 men are presenting with metastatic disease. Now, only 4% of men are presenting with metastatic disease, and that has to be due to PSA screening.”
Previous research revealed a significant decrease in screening frequency in two cohorts of men studied from June-November 2011 and during the same 6-month period in 2012 after the USPSTF guideline (8.6% vs 7.6%,P= .0001; adjusted odds ratio 0.89; 95% CI, 0.83-0.95).
The USPSTF recommendation against the use of prostate specific antigen (PSA) testing was handed down in May 2012. At this time, the task force gave the screening test a grade of D, meaning that there is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.
A few years following this decision, researchers found that between 2011 and 2013, in the immediate wake of the USPSTF recommendation, there was a 6% increase in the diagnosis of intermediate or higher risk prostate cancer in men and concluded that many more deaths could result from this disease.
“This was a travesty,” Gary Kirsh, MD, president of the Large Urology Group Practice Association (LUGPA)a professional association representing more than 20% of the nation’s practicing urologists, said in an interview withTargetedOnc. “Their interpretation of the literature with regard to PSA testing is hotly disputed by many experts in the field,” he said. “In the era of PSA testing, we have seen a 40% reduction in prostate cancer mortality in the United States.”
The goals of the study reported at AUA were to identify trends in PSA testing by OHSU primary care physicians before and after the recommendation was issued, to determine which age groups were impacted the most, and to identify the rate of PSA testing in men with lower urinary tract symptoms (LUTS). The USPSTF guideline was largely based on an analysis from the Pacific Northwest Evidence Based Practice Center at OHSU, noted Werntz.
Men aged >40 years who were new patients at the family or internal medicine clinic at OHSU between January 2008 and December 2013 were identified for inclusion in the study using the OHSU electronic database. Those with a history of prostate cancer or who had previously been treated by a urologist were excluded.
Researchers compared PSA testing before and after the USPSTF recommendation, with results stratified by age. They found that PSA testing for men aged 50-59 years fell from 19.2% over the 4 years 2008-2012 before the USPSTF recommendation, to 8.5% after May 2012 when the guideline was issueda reduction in screening of 56%. Similarly, for men aged 60-69 years, the rate fell by 60%, from 19.3% to 7.2%, respectively.
The researchers observed no significant difference in the frequency of PSA testing for men aged 40 to 49 years after the recommendation was issued (4.2% vs 4.4%, respectively) and for men 70 years or older (10.2% vs 9.3%, respectively).
Benign prostatic hyperplasia (BPH) or LUTS was a noted diagnosis in 3.6% of new patients examined, yet only 36% of men with this diagnosis were given a PSA test, suggesting underutilization of PSA in this symptomatic group of men. LUTS is a potential symptom of advanced prostate cancer, but current AUA guidelines suggest that PSA testing is optional. AUA guidelines do recommend a digital rectal exam (DRE), but this is often not done, Werntz noted.
Widespread use of PSA testing has contributed to the detection and overtreatment of men with low-risk, non-aggressive prostate cancer. Nevertheless, recognizing the benefits of PSA testing, the AUA updated its guidelines in 2013 to incorporate a man’s health risk, age, race, and family history.