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PSA testing rates differ among urologists, PCPs
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PSA testing rates have declined overall since the U.S. Preventive Services Task Force made a recommendation against the test, but these declines were greater among primary care physicians than urologists, according to a research letter published in JAMA Internal Medicine.
The U.S. Preventive Services Task Force (USPSTF) issued a recommendation against PSA testing for all men in 2011, according to study background. This recommendation has been linked to a decline in rates of PSA testing among men aged 50 years to 74 years, as well as a decline in cases of incident prostate cancer.
Quoc-Dien Trinh, MD
Quoc-Dien Trinh, MD, assistant professor of medicine at Harvard Medical School and urologist at Brigham and Women’s Hospital, and colleagues sought to compare the rates of PSA testing performed by PCPs and specialized urologists before and after the USPSTF recommendation.
Trinh and colleagues hypothesized that recommendation adoption would vary according to physician specialty.
The researchers accessed the National Ambulatory Medical Care Survey to obtain data on the use of PSA testing in 2010 (prior to the recommendation) and 2012 (the first year after the recommendation). They categorized health care providers as PCPs or urologists and examined the frequency of PSA testing in men aged 50 years to 74 years before and after the recommendation.
After excluding men with confirmed prostate cancer or other prostate conditions, the study included data from 1,222 men who presented for a preventive care visit with a doctor. The majority of men (90.8%; n = 1,109) were seen by a PCP; the remainder (9.2%; n = 113) visited a urologist.
PSA testing by PCPs decreased from 36.5% in 2010 to 16.4% in 2012 (OR = 0.43; 95% CI, 0.23-0.81), whereas urologist use decreased from 38.7% in 2010 to 34.5% in 2012 (OR = 0.34; 95% CI, 0.1-1.2). This difference between physician-specific testing practices reached statistical significance (P < .001).
The researchers acknowledged limitations of their study. Because of their reliance on outpatient data, these results may differ from those of studies using patient-reported data. Further, the study did not account for PSA testing that took place outside of physician outpatient visits, nor did it account for PSA testing performed at a separate appointment.
They also acknowledged that records for PSA tests ordered may not reflect PSA testing actually performed.
“Our findings suggest a differential effect of the 2012 USPSTF recommendations on PSA testing among PCPs vs. urologists,” Trinh and colleagues wrote. “Such findings likely reflect opposing perceptions among physicians on the benefit of PSA screening, conflicting guidelines (for example, the American Urological Association recommends joint decision making for men aged 55 years to 69 years), and perhaps differences in patient demographics or expectations. Moving forward, this finding emphasizes the need to continue interdisciplinary dialogue to achieve a broader consensus on prostate cancer screening.”
Rita F. Redberg, MD, MSc
The collection and analysis of data will be essential to measure outcomes associated with PSA testing and other diagnostic methods, David S. Aaronson, MD, urologist with The Permanente Medical Group in Oakland, California, and Rita F. Redberg, MD, MSc, editor-in-chief of JAMA Internal Medicine and professor and director of women’s cardiovascular services at University of California, San Francisco, wrote in an accompanying editor’s note.
“It is essential that, along with improved collection of outcomes data, we also have outcomes data on the myriad novel diagnostic and risk stratification tools rapidly becoming available, such as magnetic response imaging or ultrasound fused-guided prostate biopsy and genomic testing,” Aaronson and Redberg wrote. “Without such evidence, we can be sure that differing entrenched beliefs will only become more expensive. Meanwhile, the widespread use of the PSA test should serve as a cautionary tale of the importance of first establishing that benefit exceeds harms before recommending new cancer screening tools.” – by Cameron Kelsall
Disclosure: The researchers, Aaronson and Redberg report no relevant financial disclosures.
Perspective
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Mark A. Hallman, MD, PhD
The appropriate use of PSA screening remains controversial. Although it is clear that PSA screening shifts the population of newly diagnosed cancers toward favorable-risk disease, the benefit of PSA screening to OS, cancer-related morbidity and quality of life remain a point of interpretation and debate.
Large randomized trials of PSA screening and active surveillance of low-risk prostate cancers have produced conflicting data regarding a net benefit of PSA screening. As a result, current guidelines for the use of PSA screening lack consensus, and there is increasing variance of its implementation among health care providers. This is at least partially due to the competing interpretations of the available data and the opposing concerns of overdiagnosis and overtreatment vs. insufficient screening.
It is important to acknowledge the relatively long natural history of prostate cancer and the challenge this poses in the interpretation of prostate cancer outcomes data. The current screening guidelines reflect the outcomes of treatments and techniques that are considered by many to now be obsolete.
Enrollment to the two largest screening trials was conducted over 1.5 to 2 decades ago. Since that time, there have been numerous advances in all aspects of prostate cancer management including supplemental screening tools (PCA3, Prostate Health Index, kallikrein panels, molecular subtyping), diagnosis (MR fusion biopsies, advanced MR and PET imaging), treatment (intensity-modulated radiation therapy, advanced brachytherapy techniques, robotic surgery, novel systemic therapies), and the assessment of epidemiology and population outcomes (“big data”). These advances are complimented by improvements in supportive care and treatment of comorbid conditions that can further improve quality of life and decrease competing mortality risk for prostate cancer survivors.
Collectively, these advances are likely improving and will continue to improve the therapeutic window for prostate cancer management downstream of positive screens. Therefore, the value of prostate cancer screening by serum PSA and possibly other novel methods will continue to migrate in favor of screening. The continued rates of screening by the urologic community are likely a reflection of that optimism. Continued criticism and reassessment of prostate cancer screening recommendations reflects a healthy desire to improve outcomes for men with and at risk for prostate cancer.
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