‘Low-Value’ Prostate Cancer Screening Prevalent in Primary Care

Current guidelines recommend against screening for prostate cancer in men who are 70 years old and older, as it is considered to be ‘low value’ with little or no benefit for the individual. Yet a new study shows that testing for prostate specific antigen (PSA) and also digital rectal examinations (DRE) are both carried out frequently in older men, even when there is no indication for such testing.

“As a man ages, the risk for a false-positive result increases,” said lead author Chris Gillette, PhD, associate professor of physician assistant studies at Wake Forest University School of Medicine, Winston-Salem, North Carolina, in a statement

The study authors looked at primary care visits for men who were age 70 or older, and found that per 100 visits, there were 6.7 PSA tests and 1.6 DRE performed.

Gillette and colleagues emphasize the importance of their findings. Whereas prior studies have relied on commercially insured men or patient-reported rates of PSA testing, they used a nationally representative clinical dataset that is much more inclusive, as it includes men who are also uninsured or insured through traditional Medicare.

The study was published online in the current issue of the Journal of the American Board of Family Medicine.

Screening for prostate cancer has been much debated, and the guidelines have changed in recent years. As previously reported by Medscape Medical News, in the period 2012–2018, the US Preventive Services Task Force (USPSTF) had recommended against PSA-based screening in all men, but then the guidelines changed, and the Task Force subsequently endorsed individualized screening in those aged 55-69 years after a shared decision-making discussion. That same 2018 update also recommends against PSA screening in men over the age of 70.

In addition, the American Urological Association has recommended against PSA-based prostate cancer screening for men over the age of 70 since 2013.

Previous studies have shown that clinicians are not adhering to the guidelines. An analysis conducted last March found that about 1 in 4 accredited US cancer centers fails to follow national guidelines for PSA testing to screen for prostate cancer. Contrary to national guidelines, which advocate shared decision-making, 22% of centers recommend all men universally initiate PSA screening at either age 50 or 55 and another 4% of centers recommend this before age 50, earlier than the guidelines advise.

In the current study, Gillette and colleagues conducted a secondary analysis of the National Ambulatory Medical Care Survey datasets from 2013-2016 and 2018. The dataset is a nationally representative sample of visits to non-federal, office-based physician clinics. This analysis was restricted to male patients aged 70 years and older who visited a primary care clinic.

The team found that healthcare professionals who order a lot of tests are more likely to order low-value screening such as PSA and DRE.

The data also showed that when there were a higher number of services ordered/provided, the patients were significantly more likely to receive a low-value PSA (odds ratio [OR] = 1.49) and a low-value DRE (OR = 1.37). In contrast, patients who had more previous visits to the clinician were less likely to receive a low-value DRE (OR = 0.92).

Overall, there a decline in low-value PSA screening after 2014, but this trend was not seen for DRE during primary care visits.

Speculating as to why these low-value tests are being carried out, Gillette suggested  that healthcare professionals might be responding to patient requests when ordering these screening tests,  or they may be using what’s known as a ‘shotgun’ approach to medical testing where all possible tests are ordered during a medical visit.

“However, as healthcare systems move toward a more value-based care system — where the benefit of services provided outweighs any risks — clinicians need to engage patients in these discussions on the complexity of this testing,” he commented. “Ultimately, when and if to screen is a decision best left between a provider and the patient.”

There was no outside funding and the authors report no relevant financial relationships.

J Am Board Fam Med. Published online January 2, 2023. Full text

Roxanne Nelson is a registered nurse and an award-winning medical writer who has written for many major news outlets and is a regular contributor to Medscape.

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