Has ordering of PSA screening dropped among PCPs?

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An examination of data involving more than 63,000 PSA tests ordered by primary care physicians reveals some surprising findings.

Despite the U.S. Preventive Services Task Force advising against PSA-based screening for prostate cancer, physicians appear not to be cutting back.

While some have claimed that the task force recommendations against PSA screening have caused a major change in prostate cancer screening, a new study by researchers at the UT Southwestern Medical Center, Dallas revealed the use of PSA for prostate cancer screening was unaffected by changes in these controversial guidelines.

“There’s been a lot of press about PSA testing and the impact of the U.S. Preventive Services Task Force recommendations for PSA screening, and some survey-based reporting that the utilization of testing had gone down,” lead author Yair Lotan, MD, of UT Southwestern’s Harold C. Simmons Comprehensive Cancer Center, told Urology Times. “I was interested in seeing how this impacted our institution, since a large number of primary care physicians work at the university, and I wanted to see if these recommendations impacted their behavior.”

Turns out, it didn’t. The study, published online in Cancer (Sept. 22, 2016), involved examining data from 275,000 patient visits involving more than 63,000 PSA tests ordered for both inpatient and outpatient services during the years 2010-2015. The 5-year review revealed the number of tests ordered by primary care physicians was similar before and after the revised guidelines.

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The testing excluded patients who have cancer, so researchers removed any PSA testing by radiation oncologists, urologists, and medical oncologists.

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“We found there was not a significant decrease in PSA utilization and we really looked across age groups and ethnicities, and didn’t really find a big impact,” Dr. Lotan said. “The only thing we found was a slightly higher level of PSA at the time of referral, but the overall utilization of PSA was not impacted by the task force recommendations.”

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Although there has been a 39% decrease in prostate cancer mortality since 1991, the time PSA screening became widespread, controversy about the benefits and harms of PSA-based screening remains. Many physicians, however, feel any potential harms of overtreatment are outweighed by the possible benefits of early detection.

“Unlike prior studies that mainly utilized surveys to determine use of PSA testing, our study evaluated actual PSA testing performed by physicians. This accounts for physician behavior and to some extent patient preferences,” Dr. Lotan said. “One of the problems is if you follow the U.S. Preventive Services Task Force recommendation against PSA screening and don’t even discuss it with patients, you are not giving your patient the important option of screening. You have to be honest about discussing the pros and cons and help inform patients about the value of PSA testing.”

According to the National Cancer Institute, approximately 180,890 men will be diagnosed with prostate cancer this year, and about 14% of men will be diagnosed some time during their lifetime.

The U.S. Preventive Services Task Force is an independent, volunteer panel of national experts appointed by the Agency for Healthcare Research and Quality to make recommendations on preventive services such as screenings, counseling services, and preventive medications. Their guidelines on PSA testing as a screening tool are voluntary.

“One of the most disappointing things about the current climate regarding PSA screening, at least from the standpoint of the U.S. Preventive Services Task Force, is the main study [from] which it is based had an almost 90% contamination rate in the arm that was not supposed to get the PSA screening,” Dr. Lotan said. “Essentially, the study was supposed to compare one group who had PSA screening to another that did not and it turned out that both groups had very similar rates of PSA use. So it is no surprise that there was no difference in survival between the two groups. In a better designed European study, PSA screening did improve survival.”

With the study complete, researchers are now looking at the data and trying to determine which physicians were more likely to listen to the guidelines and which were not, and if any significant patterns emerge.