Decreased PSA Screening and Decreased Diagnosis of Early-Stage Prostate Cancer


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While the 2008 USPSTF recommendations against PSA screening in men aged 75 years or older were not associated with changes in screening practices, we found a decrease in the prevalence of PSA screening following the 2012 recommendations, particularly in men younger than 75 years.
— Jesse D. Sammon, DO, and colleagues

Recent data indicate that the rate of prostate-specific antigen (PSA) screening and the rate of diagnosis of early-stage prostate cancer have decreased since a 2012 U.S. Preventive Services Task Force (USPSTF) statement (released in October 2011) gave a grade D recommendation against PSA screening for all men. As reported by Jesse D. Sammon, DO, of Brigham and Women’s Hospital and Henry Ford Hospital, and colleagues in a research letter in JAMA,1 the screening rate has not significantly decreased in men aged ≥ 75 years, despite the 2012 recommendations and a 2008 USPSTF recommendation against PSA screening in this age group. As reported by Ahmedin Jemal, DVM, PhD, of the American Cancer Society, and colleagues in JAMA,2 the incidence of prostate cancer in men aged ≥ 50 years decreased by 16% between 2011 and 2012.

Study of Screening Patterns

In the study by Sammon and colleagues, the prevalence of PSA screening was determined with data from 20,757 men in the 2000 (n = 4,698), 2005 (n = 5,111), 2010 (n = 4,598), and 2013 (n = 6,350) National Health Interview Surveys (NHIS). Men aged ≥ 50 years who reported PSA testing within the 12 months preceding each survey were considered to have undergone screening.

The prevalence of screening was 34% in 2000 and 2005 and decreased from 36% in 2010 to 31% in 2013. The decrease was significant in men aged < 75 years (odds ratio [OR] = 0.78, 95% confidence interval [CI] = 0.70–0.88) but not among men aged ≥ 75 years (OR = 0.85, 95% CI = 0.66–1.10). The largest declines were seen among men aged 50 to 54 years (from 23% to 18%, OR = 0.71, 95% CI = 0.56–0.91) and 60 to 64 years (from 45% to 35%, OR = 0.69, 95% CI = 0.54–0.89).


Both the incidence of early-stage prostate cancer and rates of PSA screening have declined and coincide with [the] 2012 USPSTF recommendation to omit PSA screening from routine primary care for men. Longer follow-up is needed to see whether these decreases are associated with trends in mortality.
— Ahmedin Jemal, DVM, PhD, and colleagues

Among 10,498 men in the 2010 and 2013 surveys, likelihood of screening was significantly lower in men in the 2013 survey vs 2010 survey (OR = 0.79, 95% CI = 0.71–0.88). Men aged 50 to 54 years showed the greatest decline in screening between 2010 and 2013 compared to other age groups. In analysis adjusting for patient factors, the reduction in screening associated with release of the 2012 USPSTF recommendations was significant (P < .001).

The investigators concluded: “While the 2008 USPSTF recommendations against PSA screening in men aged 75 years or older were not associated with changes in screening practices, we found a decrease in the prevalence of PSA screening following the 2012 recommendations, particularly in men younger than 75 years.”

Study of Cancer Incidence and Screening Patterns

In the study by Jemal and colleagues, age-standardized prostate cancer incidence by stage from 2005 to 2012 in men aged ≥ 50 years was determined using data from 18 Surveillance, Epidemiology, and End Results (SEER) registries (N = 446,009), and PSA screening rate in the past year among men aged ≥ 50 years was determined from 2005 (n = 4,580), 2008 (n = 3,476), 2010 (n = 4,157), and 2013 (n = 6,172) NHIS data.

Prostate cancer incidence per 100,000 men was 534.9 in 2005, 540.8 in 2008, 505.0 in 2010, and 416.2 in 2012. The largest decrease was from 498.3/100,000 in 2011 to 416.2/100,000 in 2012—an absolute decrease of 82.1/100,000, which represents a 16% decrease (incidence ratio = 0.84, 99% CI = 0.82–0.85).

The number of men diagnosed with prostate cancer declined by 33,519 from 2011 to 2012—from 213,562 to 180,043. The declines in incidence observed since 2008 were confined to local/regional-stage disease and were generally similar across age and race/ethnicity groups. The largest decrease in local/regional-stage disease occurred between 2011 and 2012, from 447.2 to 367.3/100,000, representing a decrease of 18% (incidence ratio = 0.82, 99% CI = 0.81–0.84). The incidence of distant-stage disease generally remained stable, except for a significant increase between 2011 and 2012 in men aged ≥ 75 years (from 57.7 to 65.0/100,000); this increase was confined to white men.

Trends in Prostate Cancer Screening and Incidence

  • Frequency of PSA screening has declined significantly in men aged 50 to 74 years and nonsignificantly in those aged ≥ 75 years.
  • The incidence of prostate cancer significantly declined between 2011 and 2012.

The prevalence of PSA screening was 36.9% in 2005, 40.6% in 2008, 37.8% in 2010, and 30.8% in 2013, representing an increase of 10% (screening rate ratio = 1.10; 99% CI = 1.01–1.21) between 2005 and 2008 and a decrease of 18% (screening rate ratio = 0.82, 99% CI = 0.75–0.89) between 2010 and 2013. Among men aged ≥ 75 years, likelihood of screening decreased nonsignificantly between 2008 and 2010 (adjusted rate = 50.1% vs 43.1%, adjusted screening rate ratio = 0.86, 99% CI = 0.71–1.04) and between 2010 and 2013 (36.3%, screening rate ratio = 0.84, 99% CI = 0.68–1.05). Among men aged 50 to 74 years, the decrease between 2010 and 2013 was significant (36.8% vs 29.9%, adjusted screening rate ratio = 0.81, 99% CI = 0.74–0.89).

The investigators concluded: “Both the incidence of early-stage prostate cancer and rates of PSA screening have declined and coincide with [the] 2012 USPSTF recommendation to omit PSA screening from routine primary care for men. Longer follow-up is needed to see whether these decreases are associated with trends in mortality.” ■

Disclosure: The study reported by Sammon et al was supported in part by a grant from the Vattikuti Urology Institute. The study reported by Jemal et al was supported by the American Cancer Society. For full disclosures of the study authors, visit jama.jamanetwork.com.

References

1. Sammon JD, Abdollah F, Choueiri TK, et al: Prostate-specific antigen screening after 2012 US Preventive Services Task Force recommendations. JAMA 314:2077-2079, 2015.

2. Jemal A, Fedewa SA, Ma J, et al: Prostate cancer incidence and PSA testing patterns in relation to USPSTF screening recommendations. JAMA 314:2054-2061, 2015.


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