Prostate specific antigen screening declines after 2012 USPSTF recommendations

Researchers at Case Western Reserve University and University Hospitals Case Medical Center have assessed the impact of the 2012 U.S. Preventive Services Task Force (USPSTF) recommendations against routine prostate specific antigen (PSA) cancer screenings, which cited evidence that the risks of screening outweigh the benefits. Results of the current study indicate that the USPSTF recommendations have resulted in a decrease in the number of PSA screenings ordered by doctors, with the greatest decline seen among urologists. The findings are published in the June issue of The Journal of Urology.

PSA screening has not been without controversy. While early detection is the key to treating prostate cancer, routine PSA screenings have come under scrutiny because of potential over diagnosis and overtreatment of "clinically insignificant" prostate cancer.

In the current study, investigators looked at data for PSA tests performed at University Hospitals Case 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.

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," says lead investigator Dr. Robert Abouassaly, MD, MSc, Assistant Professor of Urology at Case Western Reserve University School of Medicine and University Hospitals Case Medical Center. "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."

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

While there is a perceived benefit by some doctors and patients for routine PSA screening, for most men who have an average risk of prostate cancer, an early diagnosis and subsequent aggressive treatment may lead to decreased quality of life. Currently the medical community remains divided on the merits of PSA testing for everyone. "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 over diagnosis and overtreatment," concludes Dr. Abouassaly. "Further study will be needed to determine the long-term effects of these recommendations on screening, diagnosis, treatment, and prognosis of this prevalent malignancy."