PSA Screening for Prostate Cancer Declines in US

Fran Lowry

March 21, 2014

Prostate-specific antigen (PSA) testing has declined in the United States, and greatest decline in use is among urologists, according to a study published online in the Journal of Urology.

The decrease followed the US Preventive Services Task Force (USPSTF) recommendation against the routine use of PSA testing, which concluded that the test is associated with more potential harm than benefit. The USPSTF issued a draft recommendation in October 2011 and the final recommendation in May 2012.

"I hypothesized that the 2012 recommendations would affect clinical practice, but I wasn't sure how quickly it would do so or what the magnitude of the impact would be," said senior author Robert Abouassaly, MD, from Case Western Reserve University and University Hospitals Case Medical Center in Cleveland.

Dr. Robert Abouassaly

"The fact that the greatest decline was seen among urologists was surprising to us because the American Urological Association still considers PSA screening an option, and actually recommends that urologists have a conversation with their patients about screening," he told Medscape Medical News.

Academic Urologists Showed the Greatest Decline

Dr. Abouassaly and colleagues analyzed the records of all PSA screening tests performed from January 2008 to December 2012 at University Hospitals and 7 affiliated hospitals located in urban, suburban, and rural settings.

The researchers evaluated the PSA screening patterns of urologists, internists, family medicine physicians, and oncologists.

Most tests were ordered by specialists in internal medicine (64.9%), followed by family medicine (23.7%), urology (6.1%), and hematology/oncology (1.3%).

PSA screening was on the increase until 2009, when 2 large randomized trials showed no significant benefit for prostate cancer.

One study, conducted in the United States, concluded that PSA screening provided no significant benefit to prostate cancer (N Engl J Med. 2009;360:1310-1319).

The other, conducted in Europe, showed that PSA screening decreased the rate of prostate cancer, although the number needed to treat was high (N Engl J Med. 2009;360:1320-1328).

After these studies were published, PSA screening decreased. And after the USPSTF recommendation against routine PSA screening, which cited evidence that the risks for screening outweighed the benefits, it decreased even further in all subspecialties except family medicine.

The greatest decrease in PSA screening was seen at the urban University Hospitals (ß = –0.138; P < .001). The decrease was particularly pronounced in men 50 to 59 years of age, but also affected men 70 to 79 years of age.

Will This Lead to More Prostate Cancer Deaths?

"We want to know if this change in clinical practice will result in a greater number of patients being diagnosed with symptoms and more advanced disease, and whether, over the long term, it will result in an increase in mortality from prostate cancer," Dr. Abouassaly said.

"Over the last decade or more, we've noticed a decrease in mortality from prostate cancer on a national level. Some of that is thought to be because of our screening practices, and the concern is that if we stop screening patients, the decline in mortality from prostate cancer might change, he said.

Whether or not to undergo PSA screening is a real dilemma for men, Dr. Abouassaly noted.

"Until we come out with a better screening tool for prostate cancer, we will continue to have this debate," he said. "In the near future, newer screening tests — genetic-based or other types — may improve the risk/benefit ratio and make it more favorable to screen men."

"Waiting until men become symptomatic from their prostate cancer is often too late. By then, they are often incurable. We don't want to go back to those days," he explained.

When the USPSTF Talks, Doctors Listen

Dr. Marc Garnick

"This study is actually pretty important for a variety of reasons," said Marc Garnick, MD, from the Beth Israel Deaconess Medical Center in Boston, who was not involved in the study.

"First, it indicates that when the task force gives a D recommendation [against routine PSA screening], it can actually have traction," Dr. Garnick told by Medscape Medical News.

Second is the fact that urologists at academic centers had the biggest decrease in use. "This is of great interest because at academic centers, you've got peers who tend to be evidence-based. If you are considered an outlier, you come under greater scrutiny [there] than if you were in a place where people are not keeping up with current recommendations and there is not a lot of peer pressure," he explained.

Testing Has Not Reduced Prostate Cancer Mortality

"The underlying hypothesis for screening is that prostate cancer starts as a microscopic focus, then becomes clinically localized, regionally advanced, metastatic, and eventually kills the patient," said Dr. Garnick, who is also editor-in-chief of the Harvard Medical School Annual Report on Prostate Diseases.

"It seems reasonable to expect that early detection would show improvement, not only in overall survival, but also in cancer-specific survival. But every single study on screening has not been able to show that," he said.

"Even though we are picking up PSA values that measure a billionth of a gram of a protein in the blood stream, we have not altered the natural history of this disease, because most of the cancers we find are cancers that would never become manifest during the patient's lifetime," he noted.

Dr. Garnick said he agrees "absolutely" with the USPSTF recommendation against widespread PSA screening for prostate cancer.

"It is interesting that the American Urological Association, which was vehemently against the task force guidelines, has done a complete 180, and now is following them," he said. "The decrement in PSA screening does not surprise me."

Dr. Abouassaly and Dr. Garnick have disclosed no relevant financial relationships.

J Urol. Published online December 14, 2013. Abstract

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