US guideline may have led to drop in PSA testing among primary care physicians, studies find

The controversial US Preventive Services Task Force (USPSTF) guidelines that recommended against routine prostate cancer screening with the prostate specific antigen (PSA) test may be changing the practice of primary care physicians in the United States, two small studies have shown.

The USPSTF issued its recommendation in 2012 after concluding that the reduction in prostate cancer mortality 10 to 14 years after the introduction of PSA based screening was “at most, very small, even for men in the optimal age range of 55 to 69 years,” while the risk of harm from follow-up studies and treatment was substantial.1 The USPSTF recommendations applied to men without symptoms who did not have a history of prostate cancer.

Many urologists, however, have disagreed with the USPSTF’s conclusions, and the American Urological Association currently recommends that PSA screening should be based on a shared decision making process for men aged 55 to 69.2 Nevertheless, two studies presented on 17 May at the association’s annual meeting showed that the USPSTF recommendations may be reducing the use of PSA testing among primary care physicians.

In the first study, researchers at Oregon Health and Science University (OHSU) in Portland, Oregon, found that PSA testing by primary care physicians had dropped significantly after the USPSTF released its findings.3 OHSU is the home of the Northwest Evidence Based Practice Center, which provided the analysis on which the USPSTF based its recommendations.

In the study Ryan Werntz, lead author and urologic surgery resident at the university, and his colleagues compared PSA testing at OHSU’s Family Medicine and Internal Medicine clinics before and after the task force made its recommendations.

The researchers identified 12 345 men who were seen as a new patient appointment from 2008 to 2013. They found that, before the task force published its recommendations, 1463 (14%) of these patients received a PSA test, while after the recommendations were released only 223 (7%) were tested (P<0.0001).

No significant difference was found in PSA testing frequency before and after the 2012 recommendations in men aged 40 to 49 (4.2% v 4.4%) or in men over 70 (10.2% v 9.3%), but significant decreases were seen in PSA testing in men aged 50 to 59 (19.2% v 8.5%; P<0.0001) and 60 to 69 (19.3% v 7.7%; P<0.0001).

In a second study Jennifer Yates, lead author, and her colleagues at the University of Massachusetts Medical School in Worcester, Massachusetts, sent a survey to 350 primary care physicians at a single academic healthcare system, 73 (21%) of whom responded.4 They found that 97% were “somewhat” or “very familiar” with the 2012 USPSTF recommendations, 80% believed that routine screening offers more harm than benefit to patients, and 75% said that they had changed their PSA testing practices because of the USPSTF statement.

Of those who had changed their practices, 11.3% went from routinely recommending PSA screening to recommending against screening, 15.09% went from a neutral stance to recommending against screening, 60.8% went from routine recommendation to a shared decision making process that allows the patient to decide, and 13.21% went from routinely discussing PSA testing to discussing it only if the patient brings it up.