Many Cancer Centers May Not Be Following PSA Screening Advice

Megan Brooks

March 10, 2022

A recent analysis found that about 1 in 4 accredited US cancer centers fails to follow national guidelines for prostate-specific antigen (PSA) testing to screen for prostate cancer.

Contrary to national guidelines, which advocate shared decision-making, 22% of centers recommend all men universally initiate PSA screening at either age 50 or 55 and another 4% of centers recommend this before age 50, earlier than the guidelines advise.

What is going on?

"We don’t know for sure. Our data could not inform why many centers are not following guidelines," Jennifer Marti, MD, with NewYork-Presbyterian/Weill Cornell Medicine in New York City, told Medscape Medical News.

Marti suspects the reasoning is well-intentioned. "Many of us in medicine intuitively think that screening for disease is a good thing because it allows us to catch a cancer early and save lives," she said.

But, she cautioned, not all early-stage cancers need to be detected and treated, and in the case of PSA screening, "more is not always better."

The study was published online March 7 in JAMA Internal Medicine.

The US Preventive Services Task Force (USPSTF), American Cancer Society (ACS), and American Urological Association (AUA) all recommend that men engage in shared decision-making with their healthcare professional about whether to start PSA screening at age 50 or 55. Most also recommend ending PSA screening at age 70 years or in men with less than 10 years of life expectancy.

The guidelines reflect evidence that PSA screening can catch cancers earlier before they spread and may reduce prostate cancer-specific mortality.

However, the guidelines also consider that screening can lead to harms, such as false-positive results or treatment for indolent tumors, and may not reduce the risk of all-cause mortality.

In the current analysis, Marti and colleagues explored whether cancer centers follow the current recommendations. The team reviewed the 2021 PSA screening guidelines posted to the websites of 1119 cancer centers accredited by the Commission on Cancer, including 64 National Cancer Institute (NCI)-designated centers. 

They compared the website recommendations with those of the USPSTF, ACS and AUA, focusing on age, shared decision-making, and potential harms.

Of the 607 centers providing recommendations on their websites, 451 (74%) advised patients and providers to discuss screening, in line with national guidelines. Of these, about one third (n = 209) recommended starting these discussions at age 50 and 17% (n = 106) at age 55.

However, contrary to national guidelines, 26% (n = 156) advised that all men universally initiate PSA screening, with 4% (n = 22) recommending starting before age 50, 19% (n = 114) at age 50, and 3% (n = 16) at age 55. The NCI-designated centers were less likely than non–NCI-designated centers to advise shared decision-making and more apt to recommend universal screening without discussion (46% vs 24%; P = .009).

Among centers providing recommendations, 476 (78%) did not state an upper age limit at which men should end prostate cancer screening, in contrast to most national guidelines, which advise stopping at age 70.

Only 229 of the 607 centers (38%) acknowledged the potential harms of PSA screening, and only 116 (19%) of them spelled out the specific risks.

The researchers say a limitation of their analysis is that the recommendations posted on an institution's website may not reflect an individual oncologist's practice.  

The problem, according to Bobby Liaw, MD, may also come down to inadequate website maintenance.

"I wonder how much of this [discrepancy] is just some centers not updating their websites with the latest guidelines," said Liaw, clinical director of genitourinary oncology, Mount Sinai Health System in New York City, who was not involved in the study.

Alternatively, Liaw suggested, the task may fall to someone without full medical expertise who does not understand the nuances of these guidelines.

Still, the discrepancies between the institutional recommendations and guidelines from the professional societies and USPSTF suggest a potential to screen patients who don't need it or won't benefit.

Take an 80-year-old man who has early-stage prostate cancer, Marti said.

The patient will most likely die of other causes before the prostate cancer causes any problems. Screening that patient and finding cancer will only do harm — introducing a stressful diagnosis and difficult treatment. That is why shared-decision making is so important.

"These are the kinds of conversations physicians and patients should have before doing a cancer screening test," Marti said.

Liaw said the study was "a little eye opening" and hopes, regardless of what an institution's website says, that "centers are adhering to the guidelines."

The study had no specific funding. Marti and Liaw have disclosed no relevant financial relationships.

JAMA Intern Med. Published online March 7, 2022. Research Letter

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