US Recommendations Against PSA Test Taken to Heart by PCPs

Pam Harrison

February 11, 2016

Primary care providers in the United States appear to have taken recent task force guidelines to heart, virtually halving their use of prostate specific antigen (PSA) testing to routinely screen men for prostate cancer.

In contrast, urologists in the United States dropped their use of PSA testing by only a fraction during the study period, new research shows.

In late 2011, the US Preventative Services Task Force (USPSTF) issued a recommendation against PSA screening for all men in 2012, citing concerns that widespread screening identified indolent tumors that did not require treatment and for which treatment could have adverse consequences.

The new study compared PSA testing in 2010 and 2012 to assess the impact of the new recommendations. The findings were reported in a research letter published online February 8 in JAMA Internal Medicine.

"Definitely we should not be ordering as much prostate cancer screening testing as we are ordering now," Charles Vega, MD, health sciences clinical professor of family medicine, University of California, Irvine, told Medscape Medical News. He was not involved in the study and was approached for comment.

"But at the same time, the study did not delve into any detail as to why the tests were ordered, and anyone in a urologist's office may have more advanced reasons to be there ― they may be symptomatic, and these are the patients who actually need the PSA as a diagnostic test for potential prostate cancer," he added.

"So I think the types of patients seen in a urologist's office vs primary care can be quite different, so that's one limitation of the study," Dr Vega commented.

Study Details

Under lead author Michael Zavaaski, MD, Brigham and Women's Hospital, Boston, Massachusetts, investigators used the National Ambulatory Medical Care Survey to examine the use of PSA testing in 2010 before the guidelines took effect and again in 2012 after they had been issued.

The investigators included all visits for men aged 50 to 74 years who presented to urologists (1222) or primary care providers (1109) for a preventive care visit.

The weighted sample that was subsequently analyzed included 27 million visits in 2010 and 2012. Of these, 800,000 examinations were provided by urologists, and 26.2 million were provided by primary care providers.

Between these two time points, PSA testing dropped by 57% in visits to primary care providers, from 36.5% in 2010 to 16.4% in 2012 (P = .009).

In contrast, PSA testing dropped by only about 4% in urology visits, from 38.7% in 2010 to 34.5% in 2012 (P = .09).

The difference between the two groups of physicians administering PSA tests during the study years was statistically significant (P < .001).

"There is a great deal of controversy about if, and how, we should screen for prostate cancer," senior author Quoc-Dien Trinh, MD, Brigham and Women's Hospital, Boston, Massachusetts, told Medscape Medical News in written correspondence.

"Moving forward, [our] findings emphasize the need to continue interdisciplinary dialogue to achieve a broader consensus on prostate cancer screening," the study authors state.

Dr Trinh elaborated that there are many forms of "dialogue," of which national recommendations or consensus statements are the first step.

"If the CMS [Centers for Medicare and Medicaid Services] or private payers start incentivizing or penalizing the use of certain tests for certain individuals, this will ultimately lead to more uniform practice patterns, for better or for worse," she observed. (As part of a federal effort to improve healthcare quality and reduce testing that is not recommended, Medicare is currently considering imposing a penalty on physicians who perform nonrecommended prostate cancer screening with the PSA test.)

Dr Vega was more supportive of the 2012 USPSTF recommendations.

"I believe and stand by the USPSTF recommendations, given the failure of any major trial to really demonstrate any change in the risk in overall mortality associated with prostate cancer screening," he said.

"The PSA screening test doesn't have to be thrown out entirely, but if a middle-aged male comes in and their PSA is very low, the risk of them developing prostate cancer is actually quite low, so I don't think the concept of screening every single year has merit — it's wasteful and exposes people to harm," Dr Vega added.

"I think there are other strategies for using PSA which could be viable, but the traditional model of screening every year is exactly what the USPFTF does not want us to do."

Continued Perception of Benefit

In a related commentary, JAMA Internal Medicine editors David Aaronson, MD and Rita Redberg, MD, write that the vast majority of PSA testing is still performed by primary care physicians.

However, "there seems to be a continued perception, more firmly held by urologists than by primary care physicians, that the screening is beneficial," they write.

Urologists may believe this possibly because they have seen more poor outcomes from metastatic prostate cancer or because they have simply referred more men who requested PSA testing, Dr Aaronson and Dr Redberg speculate.

"Recent data show some decline in the detection of early-stage prostate cancer, which likely reflects decreased ordering of PSA tests, and hopefully indicates avoidance of harms of cancer treatment, such as erectile dysfunction and urinary incontinence," they state.

"Meanwhile, the widespread use of the PSA test should serve as a cautionary tale of the importance of first establishing that benefit exceeds harms before recommending new cancer screening tests."

Many organizations, including the World Health Organization, the National Health Service in the United Kingdom, and the American Academy of Family Physicians, also do not recommend PSA screening for prostate cancer in men at average risk.

Others, including the American College of Physicians and the American Urological Association, recommend shared decision-making for men aged 55 to 69 years who are considering PSA screening and proceeding on proceeding on the basis of the patient's values and preferences.

The study was supported by the Vattikuti Urology Institute and the Professor Walter Morris-Hale Distinguished Chair in Urologic Oncology at Brigham and Women's Hospital. The authors have disclosed no relevant financial relationships.

JAMA Intern Med. Published online February 8, 2016. Abstract, Commentary

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