The reversal of national guidance that discouraged prostate cancer screening has led to a substantial rebound in the rate of prostate specific antigen (PSA) testing, according to research published November 11 in JAMA Oncology.
PSA testing grew at a 12.5% relative increase for men ages 40 to 89 from 2016 to 2019, according to a large national cohort study of over 8 million privately insured men. Significant increases in testing were seen among patients 55 to 69 years, for whom screening is specified by the guideline. But testing also grew in men ages 40 to 54 years, and among those 70 years or older, for whom routine PSA screening is not recommended.
The increased testing rates among age groups for whom screening is discouraged highlights the need to enhance the quality of decision-making for early detection of prostate cancer, given such potential consequences as unnecessary biopsy and the overdetection of low-grade disease, according to the study's authors.
In April 2017, the U.S. Preventive Services Task Force (USPSTF) published a draft guideline that reversed its 2012 guidance advising against PSA-based screening for prostate cancer in all men, which at the time gave PSA testing a grade of D. The 2012 guidance had expressed moderate to high certainty that the harms of PSA screening outweighed the benefits.
But in the 2017 revision, the group endorsed individual decision-making on PSA testing for men 55 to 69 years -- a grade C.
After the 2012 guideline was incorporated into clinical practice, there were measurable decreases in rates of PSA testing and diagnostic biopsies, as well as the number of prostate cancers identified in the U.S. There are also increasing concerns that reductions in PSA testing associated with the 2012 USPSTF statement were associated with increases in the incidence of prostate cancers diagnosed at an advanced or metastatic stage, authors of the JAMA Oncology paper, from Yale University and the University of California, San Francisco noted.
So, the investigators set out to evaluate the association between the changes in the USPSTF guideline to a grade C recommendation and national rates of PSA testing.
"We sought to identify patterns of testing in the age group specified in the guideline -- 55 to 69 years -- as well as among those for whom screening remains without recommendation -- 40 to 54 years -- or discouraged -- 70 years or older -- by the USPSTF guideline," wrote the authors, led by Dr. Michael Leapman of Yale School of Medicine.
Their retrospective cohort study used de-identified claims data from Blue Cross Blue Shield beneficiaries 40 to 89 years from January 2013 through December 2019. The scientists calculated age-adjusted rates of PSA testing in bimonthly periods. They compared PSA testing rates for the calendar years before -- January 1 to December 31, 2016 -- and after -- January 1 to December 31, 2019 -- the change in guidelines.
Statistical analyses were applied to compare the April 2017 draft and May 2018 published USPSTF guideline with rates of PSA testing. Changes in PSA testing rates were additionally evaluated among beneficiaries within the ages reflected in the guideline: 40 to 54 years, 55 to 69 years, and 70 to 89 years, the scientists wrote.
The researchers found that between 2016 and 2019, overall the mean rate of PSA testing increased from 32.5 to 36.5 tests per 100 person-years, a relative increase of 12.5%. During the same period, mean rates of PSA testing increased:
- From 20.6 to 22.7 tests per 100 person-years among men 40 to 54 years, a relative increase of 10.1%
- From 49.8 to 55.8 tests per 100 person-years among men 55 to 69 years, for a relative increase of 12.1%
- From 38 to 44.2 tests per 100 person-years among men 70 to 89 years, for a relative increase of 16.2%
Statistical analyses showed a significantly increasing trend of PSA testing after April 2017 among all beneficiaries.
In the years leading up to the 2017 draft statement, a range of prostate cancer stakeholders, including advocacy groups, politicians, and celebrities, continued to encourage screening. The researchers theorized that the increase in PSA screening may also be associated with greater connectivity within the medical community through online social media and forums.
But making PSA testing recommendations is not an easy task. In a related opinion, also published November 11 in JAMA Oncology, Dr. Freddie Hamdy of the University of Oxford wrote that the biggest challenges to making recommendations on PSA testing as a public health screening policy for prostate cancer include avoiding overdetection of disease that would not otherwise manifest itself as clinically important; inevitable overtreatment with potential adverse effects on quality of life; and the inability to determine accurately the lethal potential of prostate cancer at diagnosis, resulting in under-treatment.
"It has been clearly demonstrated that screening by PSA testing saves lives, but at the unacceptable cost of overdetection and overtreatment," he wrote, cautioning that inappropriate PSA testing outside evidence-based recommendations should cease.