Drop-off in Prostate Screening Stirs Controversy at AUA Meeting

Data presented at the American Urological Association in New Orleans show a 50% drop in PSA testing in the years since the USPSTF issued its controversial D recommendation. Some see a "chilling" effect, but not all see a problem.

To Vanderbilt University’s Sam Chang, MD, the drop-off in prostate cancer screening since 2012 represents a “chilling effect.” To Otis Brawley, MD, chief medical officer for the American Cancer Society, the change represents more conscientious conversations between doctors and patients.

But whatever one’s point of view, the data represented Monday at the American Urological Association annual meeting in New Orleans certainly grabbed headlines: According to a study presented by Ryan Werntz, MD, the controversial 2012 guideline change from the US Preventive Task Force (USPSTF) has triggered a profound shift in clinical practice.

Werntz, a urologic resident at Oregon Health & Science University (OHSU), found that the overall rate of prostate-specific antigen (PSA) testing had dropped 50% among primary care physicians at OHSU since the guideline change.

According to a report from the meeting by Oncology Live, the decline was most significant among men aged 50 to 70 years—a group highly likely to benefit from testing.

Werntz and others echoed concerns that were heard immediately in May 2012, when the USPSTF stunned urologists and the cancer prevention community by giving the PSA test a D rating, saying the harms outweighed the benefits. “If you look back before PSA was a big part of prostate cancer screening, 20% to 25% of men would often first see a physician with back pain and be subsequently diagnosed with metastatic disease,” he told Oncology Live.

USPSTF’s 2012 change was rooted in the belief, shared by some in managed care, that widespread PSA testing was causing too many men to be biopsied and overtreated for slow-growing cancers that posed no immediate risk. This caused unnecessary complications like incontinence and impotence. But supporters of PSA testing say it has saved lives.

In March 2014, Peter R. Carroll, MD, MPH, of the University of California at San Francisco, presented updated prostate cancer screening guidelines at the 19th Annual Conference of the National Comprehensive Cancer Network (NCCN) in direct response to USPSTF, and said, “We achieved a 45% reduction in mortality in prostate cancer in the United States, in contrast with an increase worldwide. Yet, the USPSTF gives it a D.”

NCCN recommended a middle ground for PSA testing in which screening would be less frequent than and guided by risk factors. Indications for biopsies would be driven by “highly suspicious” digital rectal exams that followed an elevated PSA result.

The American Cancer Society says on its web site that the USPSTF guideline differs from its own recommendation, which calls for individual decisions based on understanding of risks. Brawley, who at the time of the 2012 recommendation was skeptical how much screening would decline, told HealthDay this week that he sees a trend away from “thoughtless” to more focused screening, “with informed decision-making going on between doctor and patient.”

Werntz’ figures from OHSU showed that PSA testing in new patients age 40 or older declined from 14% in the years prior to the recommendation to 7% in the years that followed.

Reference

Werntz R, Martinez-Acevedo AC, Conlin MJ, et al. Trends in PSA utilization by primary care physicians: impact of the USPSTF recommendation. Presented at the American Urological Association Annual Meeting; New Orleans, Louisiana, May 18, 2015. Abstract PD44-02.