Jan 16, 2014 - 7:55 am
Recommendations for prostate-specific antigen screening for prostate cancer: A national survey of radiation oncologists and urologists, "Beyond the Abstract," by Simon P. Kim, MD, MPH, et al.
Published on 11 December 2013
BERKELEY, CA (UroToday.com) - Early detection of prostate cancer through the use of prostate-specific antigen (PSA) testing has become an area of significant debate, particularly concerning the benefits and harms of screening men for prostate cancer. Since the introduction of PSA testing, proponents of screening have cited the gradual stage migration to more clinically localized disease and the declines in cancer-specific mortality.[1, 2, 3] Critics of PSA screening often point to the growing concerns of over diagnosis and associated harm to patients from prostate biopsies, as well as negative impactive on treatment-related quality of life.[4, 5, 6]
Against this backdrop, the United States Preventive Services Task Force (USPSTF) recently gave PSA screening a “D” grade, concluding that PSA screening should not be performed among men in the general U.S. population regardless of age. This policy recommendation was based on a systematic review of the 5 clinical trials examining the relative merits of prostate cancer screening in reducing cancer-specific mortality and harm associated with biopsies and primary therapy. In response, the American Urological Association (AUA) and the American Society of Clinical Oncologists recommended a more balanced approach in favor of shared decision-making with patients and physicians -- discussing the benefits and harms due to prostate cancer screening in an effort to make an informed decision, especially in light of the mixed results from the two higher quality clinical trials of prostate cancer screening.[9, 10, 11, 12]
In light of this growing controversy, evaluating the perceptions of PSA screening among radiation oncologists and urologists, who often are involved with the downstream effects of prostate cancer diagnosis and treatment, was needed. In the wake of the preliminary findings from the USPSTF, we performed a national survey of radiation oncologists and urologists about recommendations of PSA screening for men at average risk of prostate cancer, across different age groups.[8, 13] The timing of our study was particularly salient, as it had been more than a decade since a national survey was performed to assess whether radiation oncologists and urologists supported the use of PSA screening. With the discordance between clinical practice guidelines about prostate screening[7, 10, 15, 16, 17] and a recent survey of primary care providers reporting that a majority of primary care providers agreed with the grade D recommendations from the USPSTF,[18, 19] the question about physician support of PSA screening for different age groups bears particular policy relevance for prostate cancer patients, providers, and policymakers.
In this national survey, we found near universal support of PSA testing from radiation oncologists and urologists for men of average risk and aged 50 to 59 (96%) and 60 to 69 (97%) years of age. Conversely, a lower proportion of respondents recommended screening for men aged 75 to 79 (44%) and ≥ 80 (13%) years of age. Another key finding of our study was that urologists were more likely to agree with PSA screening for men 40-49 years old (adjusted odds ratio: 3.1; p < 0.001), but less likely for men 75-79 (adjusted odds ratio: 0.66; p=0.01) and ≥ 80 (adjusted odds ratio: 0.45; p=0.002) years old compared with radiation oncologists. These differences in age-based recommendations for PSA screening may reflect the variations in patient age groups seen in clinical practice, across specialties.
As a consequence, this national survey study concluded that radiation oncologists and urologists continue to see clinical efficacy in recommending PSA-based screening in an age-based targeted approach consistent with existing evidence and clinical practice guidelines. Further research is needed to understand the implications for patients, physicians, and key stakeholders about the effects of the USPSTF and other best practice guidelines on the rates of prostate cancer screening and patient-centered outcomes. However, the downstream consequences of this growing controversy about PSA screening may take years to fully understand. Our results provide context on whether specialists who commonly diagnose and treat prostate cancer patients continue to see value in PSA screening.
aYale University, Department of Urology, Cancer Outcomes Public Policy and Effectiveness Research Center, New Haven, Connecticut