In 2012, the U.S. Preventive Services Task Force (USPSTF) issued a recommendation against routine PSA screening for otherwise healthy men. Almost immediately, prostate cancer support organizations and hundreds of clinical professionals raised an outcry. While acknowledging that the non-prostate cancer specific blood test often led to over-detection and over-treatment of indolent prostate cancer, countless lives had undoubtedly been saved thanks to early detection.
It’s now over three years later. What effect has it had on primary care doctors and urologists? An interesting study from Columbia University sheds light on the impact of the 2012 decision.[i] The authors analyzed the records of patients referred to their institution (June 2011 to June 2013) due to elevated PSA. They identified 201 men whose referrals were made before the 2012 USPSTF recommendation, and 212 men after the decision (none had a biopsy or previous prostate cancer). The two groups were comparable in age, race, prostate cancer family history, PSA levels, and digital rectal exam results.
After the referral was made, the same proportion of men in each group had a biopsy, with similar diagnosis rates. In addition, the distribution of Gleason scores and prostate cancer risk factors (stage, number of cores positive, PSA values and grade) were roughly equivalent. There were no clinical differences between the pre-USPSTF and post-USPSTF groups.
However, the post-USPSTF patients were more likely to have had also had the urine test called PCA3 and a repeat PSA test, meaning more information had been taken into account before referrals were made:
Pre-USPSTF referrals (n=201)
Post-USPSTF referrals (n=212)
|Had additional PCA3 test||11%||27%|
|Had second PSA test||72%||82%|
The research team also calculated factors predictive of undergoing a biopsy; in the post-USPSTF group, African American race and family history were predictors of a biopsy, which was not so in the pre-USPSTF group.
Based on these analyses, the authors concluded that the USPSTF recommendation did not affect the number of patients referred by primary care doctors or urologists to a tertiary center (an institutional center or hospital offering specialty care). Nor was there a difference in the clinical characteristics of patients. What the recommendation appeared to have led to was a greater number of urologists ordering significantly more PCA3 and repeat PSA tests, and a drop in recommending biopsies at the initial visit. Even though the proportion of patients receiving a biopsy remained the same, greater care was taken to assess the patient’s predictors of disease after the USPSTF determination.
While the recommendation brought change in the right direction, I look forward to the day when 3T mpMRI is a routine response to a suspicious PSA, PCA3 and other tests before a random biopsy is done. Read more about the PSA controversy at https://sperlingprostatecenter.com/can-mri-imaging-resolve-the-psa-controversy/.
[i] Perez TY, Danzig MR, Ghandour RA et al. Urology. 2015 Jan;85(1):85-91.