Are the Right Men Getting Screened for Prostate Cancer?

Prostate-specific antigen (PSA)-based screening for prostate cancer increased after the U.S. Preventive Services Task Force recommended individual decision-making for men ages 55 to 69 in 2017, reversing its 2012 guidance that advised against PSA screening in all men.

Now, a retrospective cohort study found that from 2016 to 2019 the overall mean rate of PSA testing increased from 32.5 to 36.5 per 100 person-years, a relative increase of 12.5% (95% CI 1.1-24.4), reported Michael Leapman, MD, of Yale University School of Medicine in New Haven, Connecticut, and colleagues.

Among men ages 55 to 69 specifically, the mean rate of PSA testing increased from 49.8 per 100 person-years in 2016 to 55.8 per 100 person-years in 2019 (relative increase 12.1%, 95% CI -0.2 to 25.2), they noted in JAMA Oncology.

Increases were also observed among men ages 40 to 54 and in those 70 and older — age groups for which screening is not recommended.

“Increasing rates of PSA testing in age groups for whom screening remains explicitly discouraged highlights the need to enhance the quality of decision-making for early detection of prostate cancer given downstream consequences, such as unnecessary biopsy and the overdetection of low-grade disease,” wrote Leapman and colleagues.

For men ages 40 to 54, mean rates of testing increased from 20.6 to 22.7 per 100 person-years (relative increase 10.1%, (95% CI -2.8 to 23.7). And for those ages 70 to 89, these rates increased from 38.0 to 44.2 per 100 person-years (relative increase 16.2%, 95% CI 4.2-29.0).

The largest increase was observed in men ages 70 to 74, from a mean of 50.0 per 100 person-years in 2016 to 58.3 per 100 person-years in 2019, they noted.

Leapman and colleagues suggested that the increase in PSA screening among younger men may be the result of emerging evidence about the prognostic value of a patient’s baseline PSA level at middle age.

“Further study is needed to understand patient perspectives and potential quality-of-life outcomes associated with screening younger men,” they wrote. “These results should also strengthen efforts to align PSA testing with best practice, particularly for those least likely to benefit, such as men older than 75 years or those with significant medical comorbidity.”

In a commentary accompanying the study, Freddie C. Hamdy, MD, of the University of Oxford in England, noted that the prostate cancer screening landscape is continuing to evolve — as illustrated by the emergence of prebiopsy imaging with multiparametric MRI — and suggested “the long-term practice of a PSA test followed by systematic biopsies of the prostate is antiquated.”

He added that the use of imaging and targeted biopsies, as well as the potential demonstrated with genomic testing as a risk stratification approach to screening, means the field will continue to progress by minimizing the risks of overdetection and overtreatment, and focusing on identifying early disease and tailoring treatments that can improve outcomes.

“But when will the message get through to the public, clinicians, and health care professionals that inappropriate PSA testing outside evidence-based recommendations should cease?” Hamdy asked.

For this study, Leapman and colleagues used de-identified claims data from Blue Cross Blue Shield beneficiaries ages 40 to 89 (median age 53) from Jan. 1, 2013 through Dec. 31, 2019 to calculate age-adjusted rates of PSA testing in 2-month periods, and then compared testing rates in 2016, which was before the guideline change, versus 2019, which was after the change.

One limitation to the analysis, the authors acknowledged, was that the Blue Cross Blue Shield database may not be generalizable to all populations, since it includes mostly younger and more socioeconomically advantaged patients with employment-based insurance.