In May 2012, the U.S. Preventive Services Task Force (USPSTF) issued a grade D recommendation against the use of PSA-based screening for prostate cancer in men of all ages based on data showing that PSA-based screening contributes to overtreatment and overdiagnosis of prostate cancer (Ann Intern Med 2012;157:120-134).
That recommendation has sparked controversy since it was first issued. A new study analyzed the real-world data on PSA ordering and referral practices in the years surrounding that recommendation (at UT Southwestern Medical Center) to help understand its effect on practice (Cancer DOI: 10.1002/cncr.30330).
“The United States Preventive Services Task Force recommendation against PSA screening generated significant controversy,” noted study author Yair Lotan, MD, Chief of Urologic Oncology and the Helen J. and Robert S. Strauss Professor in Urology at UT Southwestern Medical Center.
“We examined a large, whole-institution dataset in the years before and after the USPSTF recommendations reflecting actual practice and found that the changes in PSA use at our institution, if any, were small,” he explained. “This is more consistent with behavior seen after the vast majority of practice recommendations.”
The researchers included 275,758 male ambulatory care visits between 2010 and 2015 at UT Southwestern Medical Center. The data did not reveal a significant change in the use of PSA-based screening as measured by the total number of PSA exams per ambulatory care visit.
Here's why Lotan said this data matters—and has implications for providers outside of UT Southwestern.
1 Why did you decide to conduct this research—and were you surprised by what you found?
“Policy regarding prostate cancer screening has important implications for men, as this is the most common cancer in men. We felt it was important to understand how the USPSTF recommendations impacted use of PSA at our large tertiary referral institution since we care for a large population of men.
“In many ways, I found the results reassuring since use of PSA did not change dramatically. I was not very surprised since I have two brothers who are internists and I am aware of how many guidelines they need to keep track of in any given year. It is difficult to change their practice with each new recommendation.”
2 The actor Ben Stiller recently wrote an essay on how a PSA test “saved his life.” His PSA test appears not to be in line with the current USPSTF recommendations. If his cancer had been discovered later, does the evidence suggest he still would have responded to treatment? Would you say that Stiller's claims are warranted?
“Ben Stiller's article provides important insight from a patient's perspective. He is correct that based on the USPSTF recommendation he may never have had screening.
“We know that prior to PSA screening many men were diagnosed only after they experienced metastatic disease. It is hard to know the impact of delayed diagnosis in any individual patient's case—but for a young man with intermediate-risk prostate cancer, there is no question that earlier diagnosis is preferable.
“In regards to current recommendations, the American Urological Association advocates for discussing the pros and cons of PSA screening with patients, which I think is a good policy so patients can make their own informed choices.”
3 What should practicing oncologists and oncology care providers outside of UT Southwestern know about this research?
“Our institution's findings may not represent the nation as a whole; however, at least one survey dataset pointed to Texas as one of the states with the largest drop in PSA use, which we did not observe. With recent revelations about the flaws in studies used in the USPSTF recommendation, we hope the USPSTF will be diligent in considering the wisdom of their initial recommendation against PSA since this can have a significant impact on health of men.
“Future research directions are many, including looking at provider factors that may influence PSA use and finding new ways to appropriately treat men with prostate cancer and avoid treatment in men unlikely to benefit from further treatment. There is also need to optimize recommendations regarding screening for prostate cancer and developing more accurate tests.”