PSA testing rates rose after USPSTF revised prostate cancer screening guideline
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PSA testing rates increased after the U.S. Preventive Services Task Force revised its guidance on prostate cancer screening in 2017, according to results of a large national cohort study in JAMA Oncology.
The task force issued guidance in 2012 advising against PSA testing for all men. The panel later reversed its guidance, endorsing individual decision-making for men aged 55 to 69 years. It does not have a recommendation on PSA testing for men aged younger than 55 years but recommended against such screening for men aged 70 years or older.
Since the guidance revision, PSA testing increased among men in all age groups, results showed.
“A strong motivator for this study comes from my clinical practice as a urologist, where patients often express deep interest in having consistent and straightforward recommendations about screening tests that can reduce their risks for prostate cancer,” Michael S. Leapman, MD, assistant professor of urology and clinical program leader in the prostate and urologic cancers program at Yale Cancer Center, told Healio. “Many patients and doctors are also bewildered by the controversies and major shifts in guidance that have occurred for PSA testing within the past decade. By studying changes in national PSA testing practices, we hope to provide greater clarity about current patterns of care, as well as the effects of major shifts in clinical guidelines.”
Leapman and colleagues analyzed de-identified claims data from Blue Cross Blue Shield beneficiaries aged 40 to 89 years (median age, 53 years; interquartile range, 47-59) from Jan. 1, 2013, through Dec. 31, 2019. A median 8.08 million beneficiaries were eligible for in each bimonthly period.
Leapman and colleagues calculated age-adjusted rates of PSA testing in bimonthly periods and compared PSA testing rates from calendar years before and after the guideline change (January to December 2016 vs. January to December 2019).
They also used interrupted time series analyses to evaluate the association of both the draft (April 2017) and published (May 2018) US Preventive Services Task Force (USPSTF) guidelines with rate of PSA testing.
Researchers further evaluated changes in PSA testing rates among beneficiaries within the age categories used in the guidelines: 40-54 years, 55-69 years and 70-89 years.
They aimed to determine whether the reversal of the USPSTF guideline advising against PSA testing had any association with utilization rates.
Results showed a relative increase of 12.5% (95% CI, 1.1-24.4) in rates of PSA testing among men aged 40 to 89 years during the study period, from a mean 32.5 tests per 100 person-years to 36.5 tests per 100 person-years.
In the same time period, mean rates of PSA increased from 20.6 to 22.7 tests per 100 person-years among men aged 40 to 54 years, equating to a relative increase of 10.1% (95% CI, –2.8 to 23.7); 49.8 to 55.8 tests per 100 person-years among men aged 55 to 69 years, equating to a relative increase of 12.1% (95% CI, – 0.2% to 25.2%); and 38 to 44.2 tests per 100 person-years among men aged 70 to 89 years, equating to a relative increase of 16.2% (95% CI, 4.2-29).
Interrupted time series analysis revealed a significant increase in PSA testing after April 2017 among all beneficiaries (0.3 tests per 100 person-years for each bimonthly period; P < .001).
“We were intrigued by the findings,” Leapman said. “Uncovering increasing use of PSA testing overall may be seen as an expected finding in light of renewed support from the guideline. However, findings of increased testing in patient groups for whom screening remains discouraged — particularly patients aged older than 70 years — raises questions about the specificity with which the change in guidelines has been implemented.”
Study limitations included that its most recent data did not take into account the likely significant effects of the COVID-19 pandemic on rates of cancer screening and PSA testing. Additionally, although the 2018 guideline noted Black men face higher risk for prostate cancer, the USPSTF did not make specific recommendations by race. Additional research is needed to examine PSA testing difference by race or other sociodemographic factors, researchers concluded.
“We are also interested in understanding downstream effects of these changes, such as differences in use of prostate biopsy, cancer diagnosis, treatment and outcome,” Leapman said.
For more information:
Michael S. Leapman, MD, can be reached at Department of Urology, Yale University School of Medicine, 310 Cedar St., BML 238C, New Haven CT, 06520; email: michael.leapman@yale.edu.
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Kevin Ginsburg, MD
Leapman and colleagues reported that after publication of the 2018 USPSTF prostate cancer screening recommendations, the rate of PSA testing rose from 32.5 to 36.5 tests per 100 person-years. This can be thought of as an additional four PSA tests being ordered among a group of 100 men for each year these men received insurance from Blue Cross Blue Shield. Importantly, the authors noted an increase in PSA testing (to various degrees) among men of all age groups, including men for whom prostate cancer screening typically is not recommended.
The 2018 recommendations were an important step to reverse some of the potential harms associated with de-emphasizing and recommending against prostate cancer screening for age-appropriate men. As many providers who treat prostate cancer know, PSA screening has played an integral role in reducing death due to prostate cancer, as well as limiting morbidity from the development of metastatic disease. The authors show the importance of national recommendations and guidelines on medical decision-making and screening, and the potential implications of these guideline statements on physicians’ behavior.
As we continue to emphasize prostate cancer screening for men who are most likely to benefit from the diagnosis and treatment of clinically significant disease, we must use PSA screening wisely and appropriately to maximize the tremendous benefit derived from screening appropriate men while minimizing potential harms from inappropriate screening.
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