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Fewer men undergoing prostate cancer screening, treatment

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May 21, 2018

Prostate cancer screening, as well as diagnoses and definitive therapy, decreased steadily from 2008 to 2014, according to findings published in Cancer.

“Serum PSA levels have been the biomarker of choice for screening of prostate cancer since the late 1980s,” James T. Kearns, MD, clinical fellow of urologic oncology at University of Washington School of Medicine, and colleagues wrote. “However, treatment of clinically insignificant prostate cancer with radical prostatectomy or radiation is associated with significant morbidity, with reported harms of erectile dysfunction and urinary incontinence.”

The U.S. Preventive Services Task Force in 2012 recommended against routine PSA screening in asymptomatic men, although the task force stated in 2018 that the choice should be left to the individual after consultation with their doctor.

“The impact of the 2012 USPSTF recommendation against PSA screening has not yet been fully characterized,” the researchers wrote.

Kearns and colleagues searched MarketScan claims — reviewing a pool of more than 30 million privately insured individuals — to identify men aged 40 to 64 years in the U.S. After excluding men with a diagnosis of prostate cancer or a prostate biopsy in the first year of enrollment, a total of 6 million men qualified for the study.

Researchers found PSA testing, biopsy, prostate cancer diagnosis and definitive therapy all declined between 2009 and 2014, with a particular decrease occurring after 2011 (P < .001).

The rate of biopsy per 100 patients who underwent PSA testing fell from 1.95 (95% CI, 1.92-1.97) to 1.52 (95% CI, 1.5-1.54).

The incidence of prostate cancer diagnosis per biopsy rose from 0.36 (95% CI, 0.35-0.36) per 100 patients to 0.39 (95% CI, 0.39-0.4).

Of patients who had a new prostate cancer diagnosis, the proportion who received definitive therapy fell from 69% (95% CI, 69-70) to 54% (95% CI, 53-55).

The incidence of both PSA screening and prostate cancer fell significantly after 2011 (P < .001).

“In addition to finding decreased prostate cancer screening, we found that fewer men were being diagnosed with prostate cancer, and even fewer men were being treated with surgery or radiation for their prostate cancer,” Kearns said in a press release. “This means that they are likely choosing active surveillance for low-risk prostate cancer. This is important because active surveillance has been shown to be safe [for] many men, and it avoids problems associated with prostate cancer treatment, such as urinary incontinence and erectile dysfunction.

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“Part of the controversy surrounding prostate cancer screening was that men who didn’t need surgery or radiation for their prostate cancer were still undergoing these treatments,” Kearns added. “If those men are instead undergoing active surveillance of their low-risk prostate cancer, then the harms of screening will be lower.”

Gaps in knowledge remain about which men would most benefit from screening, as do gaps in the delivery of prostate cancer care, Christopher Filson, MD, MS, assistant professor in the department of urology at Emory University School of Medicine, wrote in an accompanying editorial.

“The key will be performing PSA screening — in addition to biopsies and prostate cancer treatment — more intelligently, not more frequently,” Filson wrote. – by Andy Polhamus

Disclosures: The authors and Filson report no relevant financial disclosures.

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Perspective

PSA testing, prostate biopsy and local treatment for prostate cancer are in decline, according to this study. Although there are data supporting no change in the mortality regarding prostate cancer based on the PLCO trial, the management of early-stage/low-grade cancers is significantly different than the management of advanced disease. The decreased detection of early-stage prostate cancers by decreased screening will yield greater incidence of advanced disease at presentation. This paper did not comment on the clinical utility of other available tools proven to be helpful in differentiating low-grade disease from high-grade disease. These include multiparametric MRI for prostate cancer used with the Prostate Imaging Reporting and Dada System (PI-RADS). Prostate MRI with PI-RADS is a noninvasive tool that has shown high interobserver agreement to accurately differentiate high-grade disease from low-grade/no disease. There definitely is a role for prostate MRI in the screening population, which has not yet been explored.

Frederico F. Souza, MD

Miami Cancer Institute

Disclosure: Souza reports no relevant financial disclosures.