PSA screening practices appear unchanged since USPSTF recommendation

PSA ordering and referral practices have not significantly changed since the U.S. Preventive Services Task Force issued recommendations against the routine use of PSA screening in asymptomatic men, according to a study published in Cancer.

However, patients were referred for testing at progressively higher PSA levels.

“Despite a 39% decline in prostate cancer–specific mortality since 1991, controversy about the benefits and harms of PSA–based screening [remains],” Ryan Hutchinson, MD, from the department of urology at The University of Texas Southwestern Medical Center, and colleagues wrote.

In 2012, the U.S. Preventive Services Task Force (USPSTF) recommended against the use of PSA–based screening for prostate cancer in men of all ages because the harms of overtreatment outweighed the benefit of early detection.

A year later, the American Academy of Family Physicians adopted these recommendations. In addition, the American College of Physicians urged for a shared decision-making approach with men aged 50 to 69 years and advised against screening in all other ages.

“The recommendation has raised concerns that a reduction in PSA–based screening in the United States will lead to a delay in the diagnosis and an increase in the incidence of later-stage prostate cancer,” Hutchinson and colleagues wrote.

Therefore, the researchers obtained a whole-institution sample of electronic medical record PSA orders and urology referrals to evaluate referral behavior before and after the recommendation.

In total, 275,784 men reported for unique ambulatory visits between 2010 and July 2015. Of 63,722 raw PSA orders, 54,684 were evaluable.

Primary care providers ordered 17,315 PSA tests and 858 urology referrals in that time period.

The average age at the time of the urology referral, the mean number of PSA tests per 100 visits, the mean number of referrals per 1,000 visits, and the proportion of PSA tests performed outside the recommended age range did not significantly change during the study period.

However, the mean PSA results at the time of urology referral increased from 2.49 ng/mL in 2010 to 3.84 ng/mL in 2015, which represented a significant increase in both a linear regression analysis (P = .022) and the quadrative regression analysis (P = .002).

Researchers conducted joinpoint regression analyses — which identify changes in temporal trends — over the entire period for total PSA orders, PSA orders per ambulatory visit, screening PSA tests and referrals per PSA order to assess for possible pre- and postrecommendation changes in trends of PSA ordering. Results showed no additional joinpoints in total PSA orders, screening PSA tests or examinations per 100 visits.

However, a joinpoint arose in 2013 — when urology referrals per screening PSA examinations were analyzed — that “might signal a downward trend after the recommendation,” the researchers wrote.

“PSA behavior did not change significantly. Patients were referred at progressively higher average PSA levels,” researchers wrote. “The implications for prostate cancer outcomes from these trends warrant further research into provider variables associated with actual PSA utilization.”

Compared with broader reports that identified a decline in prostate cancer diagnoses since the USPSTF recommendations, these PSA practices may reflect a remote persistence of PSA ordering behavior in a local health system, James T. Kearns, MD, and John L. Gore, MD, from the department of urology at University of Washington, wrote in an accompanying editorial.

“[The practices observed in this study also raise] an important issue: what is the appropriate level of screening and referral?” they wrote “Could continued but more thoughtful PSA screening and urology referrals lead to better health outcomes among men with prostate cancer?” – by Kristie L. Kahl

Disclosure: The researchers, Kearns and Gore report no relevant financial disclosures.