Drop in PSA screening greatest among urologists

The U.S. Preventive Services Task Force (USPSTF) recommendation against routine prostate cancer screening has resulted in a decrease in the number of PSA-based screenings ordered by physicians, with the greatest decline seen among urologists, according to findings of recently published study that one leading prostate cancer expert says raises more questions than it answers.

The findings will be published in the June issue of The Journal of Urology;an uncorrected proof appears online ahead of print (Dec. 16, 2013).

Researchers at Case Western Reserve University and University Hospitals Case Medical Center in Cleveland examined data for PSA tests performed at the medical center and its affiliated facilities from January 2008 to December 2012. During that period, 43,498 PSA screenings were performed, with the majority of the tests ordered by internal medicine (64.9%), followed by family medicine (23.7%), urology (6.1%), and hematology/oncology (1.3%). Screening numbers started to decline in 2009 with the release of the initial PSA screening trial results, and then continued to decline after the USPSTF recommendations were issued in 2012.

To explore the specifics of the decline, investigators evaluated data reported for type of medical provider ordering the tests, as well as geographic location of the facility.

“The recently published prostate screening trials and the USPSTF recommendations appear to have negatively impacted PSA screening,” said lead investigator Robert Abouassaly, MD, MSc. “These effects were more immediate and pronounced in the urban/academic setting, and more gradual in suburban and rural settings. Decreased prostate cancer screening was observed across all specialties over time, with, interestingly, the greatest impact seen among urologists.”

Also somewhat surprising was the finding that, in terms of screening declines by patient age, the greatest decrease in screening was observed in the intermediate age group (50-59 years). Patients 60 years old or older also showed a decrease in PSA screening after the recommendation was released in May 2012, but this was nonsignificant.

Continue to next page for more, including commentary from UT Editorial Consultant J. Brantley Thrasher, MD.

The researchers explain that because for urologists, prostate cancer is a focal point of their daily practice, the changes in PSA screening behavior may have been more rapidly acknowledged. Primary care physician offices manage a broad range of clinical topics with varied screening policies, which may cause a delay in their implementation. Also, PSA screening policy may not quickly circulate through rural and suburban areas compared to urban/academic practices.

“Clinical practice guidelines for prostate cancer screening vary and are controversial due to uncertainty as to whether the benefits of screening ultimately outweigh the risks of overdiagnosis and overtreatment,” Dr. Abouassaly said. “Further study will be needed to determine the long-term effects of these recommendations on screening, diagnosis, treatment, and prognosis of this prevalent malignancy.”

J. Brantley Thrasher, MD, of the University of Kansas Medical Center in Kansas City, agreed that additional research on the effect of the USPSTF recommendations on prostate cancer screening is necessary.

“I think that this is a very small study comparatively and needs to be substantiated by other larger studies,” Dr. Thrasher told Urology Times, for which he serves as an editorial consultant. “The decrease in the intermediate age groups could be a function of how the authors obtained their data and the fact that they had no information on urologist referrals, why patients were seen, biopsy data, etc.

“I think a larger study is needed that addresses if we do see widespread decreases in screening by urologists, what age groups, what education tools they are using to discuss this with patients, and why did the urologists decide to stop screening in certain populations. Also, are they still screening those that are high risk based on family history or race?” added Dr. Thrasher, who was not involved in the study.

“This study really raises more questions than it answers right now, but it is interesting and deserves further study.”

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