From 2016 to 2019, rates of PSA-based testing for prostate cancer progressively increased, despite a change in U.S. Preventive Services Task Force (USPSTF) guidelines advising against PSA-based screening for prostate cancer in all men, according to results from a large, national study.
In addition to a relative increase of 12.5% overall, the greatest increase in testing—roughly 16%—occurred in men ages 70 to 89 years. The findings are published in JAMA Oncology.
In 2017, the USPSTF changed its guidelines, essential reversing its guidance from 2012 advising against PSA-based screening for prostate cancer in all men in lieu of individual decision-making for men ages 55 to 69 years old.
“In April 2017, the USPSTF published a draft guideline that reversed prior guidance against routine screening for prostate cancer, issuing a grade C recommendation for men age 55 to 69 years that the decision to undergo periodic PSA-based screening for prostate cancer should be an individual one, based on a discussion of the potential benefits and harms. The updated guideline was published in its final form in May 2018 and continued to emphasize the potential harms of screening and to discourage PSA testing for patients 70 years or older,” wrote Michael S. Leapman, MD, of Yale University School of Medicine, New Haven, Connecticut, and fellow researchers.
Leapman and colleagues undertook this retrospective study to assess changes in PSA testing after the USPSTF guideline revision. They used data from the Blue Cross Blue Shield (BCBS) Axis administrative claims database, which consists of 36 health organizations and companies that provide care for about one-third of all Americans.
Leapman et al calculated PSA testing bimonthly, as well as PSA testing from calendar years both prior to the guideline revision (Jan. 1-Dec. 31, 2016) and after it (Jan. 1-Dec. 31, 2019). Each bimonthly assessment period included a median of slightly more than 8 million eligible beneficiaries, with a median age of 53 years.
The mean rate of PSA testing increased between 2016 and 2019, from 32.5 to 36.5 tests/100 person-years, respectively, or a relative increase of 12.5% (95% CI: 1.1%-24.4%). Researchers also found increases in the mean rates of PSA testing when analyzed by age, as follows:
- In men age 40-54 years, rates increased by 10.1%, from 20.6 to 22.7 tests/100 person-years (95% CI: −2.8% to 23.7%).
- In men age 55-69 years, testing rates increased by 12.1%, from 49.8 to 55.8 tests/100 person-years (95% CI: −0.2% to 25.2%).
- In men age 70-89 years, rates increased by 16.2%, from 38.0 to 44.2 tests/100 person-years (95% CI: 4.2%-29.0%).
Upon conducting an interrupted time series analysis, Leapman and fellow researchers found a significantly increasing trend of PSA testing among all beneficiaries after April 2017 (0.30 tests/100 person-years for each bimonthly period; P˂0.001), which coincides with the release of a draft of the revised USPSTF guidelines for PSA testing.
In an accompanying editorial, Freddie C. Hamdy, MD, of the University of Oxford, U.K., applauded the study by Leapman et al, and expressed concern for what their results reflect—”a flawed attitude toward PSA testing in the community.”
He wrote: “Based on emerging evidence from these few global randomized clinical trials, the USPSTF made recommendations in 2012 that PSA testing should not be offered to any man at any age with the purpose of prostate cancer screening (grade D recommendation). This recommendation has been associated with a notable reduction in indiscriminate PSA testing in the U.S. but was deplored by many clinicians and institutions as in turn being associated with an increase in the number of men presenting with metastatic and advanced disease. As the trials matured, these recommendations were amended in 2018, suggesting that men between 55 and 69 years of age can be offered a PSA test but that men ages 70 years or older should not be tested.”
Hamdy noted that the catalyst for this study from Leapman et al was “the perceived increase in the presentation of late-stage disease, claimed by some as being caused by the reduction in PSA testing” and cautioned against inappropriate screening in asymptomatic men. He also warned of the risks of overdetection and overtreatment.
“The prostate cancer screening landscape continues to evolve with the emergence of prebiopsy imaging using multiparametric magnetic resonance imaging of the prostate, which has transformed the diagnostic pathway in many countries but with slower uptake in the U.S. It is now evident that the long-term practice of a PSA test followed by systematic biopsies of the prostate is antiquated. In the CAP trial, for instance, a single PSA test missed more than one-third of lethal prostate cancers in men who underwent screening. Although genomic testing and the use of other emerging risk calculators, such as polygenic hazard scores, have limited evidence to be adopted in a risk-stratification approach to screening, it is likely that with imaging and targeted biopsies, the field will progress further, minimizing the risk of overdetection and overtreatment and focusing on identifying early disease that warrants tailored treatments to improve outcomes and save lives.
“But when will the message get through to the public, clinicians, and health care professionals that inappropriate PSA testing outside evidence-based recommendations should cease?” he wondered.
Limitations of this study include the exclusion of changes in diagnostic procedures, incident prostate cancer cases, stage at diagnosis, race, family history, and characteristics and presence of shared decision-making associated with PSA testing; the inclusion of younger and more socioeconomically advantaged patients with employment-based insurance in the BCBS database. Finally, noted Leapman and colleagues, since 2019 was the most recent year included in the analysis, the effects of the Covid-19 pandemic are not accounted for.
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Researchers found a progressive and significant increase in PSA testing among men of all ages after the revision of the USPSTF grade C recommendation in 2018.
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These results raise concerns about the increases in testing for men ages 40 to 55 years and 70 years or older, which fall outside the age category in the USPSTF recommendations and may lead to potential harm.
Liz Meszaros, Deputy Managing Editor, BreakingMED™
Support for this research was provided by the National Institutes of Health/ National Cancer Institute.
Leapman reported receiving grants from the National Institutes of Health/National Cancer Institute during the conduct of the study.
Hamdy reported receiving grants from the National Institute for Health Research HTA Programme and Cancer Research UK during the conduct of the study; and personal fees from Intuitive Surgical outside the submitted work; serving as editor-in-chief, British Journal of Urology International
Cat ID: 25 Topic ID: 78,25,730,25,935,192,255,151,241,73,925Author
