Ryan Werntz, MD
When the United States Preventive Services Task Force (USPSTF) recommended against routine PSA screening for early detection of prostate cancer in May 2012, it caused a sea change in practice patterns among primary care physicians.
The impact of the recommendations had “a significant chilling effect,” said Sam Chang, MD, a professor of Urology at Vanderbilt University Medical Center, who moderated a panel discussion on the topic at the 2015 American Urological Association (AUA) Annual Meeting.
Data presented by Ryan Werntz, MD, during the panel discussion showed that after the guideline was issued, the overall rate of PSA testing decreased by 50% among primary care physicians at Oregon Health & Science University (OHSU).1
In particular, the most significant decrease in PSA use was seen in men aged 50 to 70 years—a cohort most likely to benefit from screening.
“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,” continued Werntz. “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).2
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 issued—a 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.
Enhanced education for primary care providers is required to stress that not every prostate cancer needs to be treated. Screening should include shared decision making with the patient and a restriction of screening and biopsy to high-risk groups of healthy men. For those at low-risk, less frequent PSA screening could be appropriate and newer tests that correlate with cancer aggressiveness could be utilized to lessen the chance of overdiagnosis and overtreatment.
“Urologists are uniquely positioned to monitor PSA test results with their patients, and to know when to biopsy an individual,” concurred Werntz. “Obviously, it should be a shared decision.”
Werntz R, Martinez-Acevedo AC, Conlin MJ, et al. Trends in PSA utilization by primary care physicians: impact of the USPSTF recommendation. Presented at: AUA Annual Meeting; May 15-19, 2015; New Orleans, LA. Abstract PD44-02.
Cohn JA, Wang CE, Lakeman JC, et al. Primary care physician PSA screening practices before and after the final US Preventive Services Task Force recommendation. Urol Oncol. 2014;32(1):41.e23-30.
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