December 2, 2021 – A previous US statement discouraging routine prostate-specific antigen (PSA) testing led to lower rates of prostate cancer screening and higher metastatic rates across racial groups – including Black men, who are at increased risk of prostate cancer, suggests a study in Urology Practice®, an Official Journal of the American Urological Association (AUA). The journal is published in the Lippincott portfolio by Wolters Kluwer.
The 2012 statement by the US Preventive Services Task Force (USPSTF) was followed by reduced rates of screening, prostate cancer biopsy, and detection and increased rates of metastatic prostate cancer, according to new research by Joseph Presti, Jr, MD, and colleagues of Kaiser Permanente Northern California (KPNC), Oakland. "Our study raises concern that policies leading to reduced prostate cancer screening might place Black men and other groups at higher risk (for example, those with a family history of prostate cancer) of adverse outcomes, such as higher metastatic rates," Dr. Presti comments.
New evidence on race-specific trends in prostate cancer screening
The 2012 statement by the USPSTF reflected a lack of evidence that PSA screening reduced the risk of death from prostate cancer. Previous studies have found that the statement was followed by reduced prostate cancer screening and biopsy rates, in general. However, those studies have not addressed the use of screening in groups at higher risk, such as Black men or patients with a family history of cancer.
In the United States, Black men have a 44 percent increased risk of death from prostate cancer, compared to White men. The USPSTF issued an updated statement in 2018, recommending shared decision-making between patients and doctors, based on discussion of the risks and benefits of PSA screening, for all men between the ages of 55 and 69. However, the USPSTF still has not recognized the need to differentially address screening in high-risk cohorts at a younger age, such as Black men or those with a family history of the disease.
To better understand the race-specific impact of the 2012 USPSTF statement, Dr. Presti and colleagues reviewed data on all men eligible for PSA screening in the KPNC system between 2006 and 2017. The eligible age range was 45 to 69 years for Black men, reflecting their higher risk of prostate cancer, and 50 to 69 years for men of other races.
The analysis included between 420,000 and 567,000 men per two-year period. About 72 percent of patients were White, 8 percent were Black, and 20 percent were Asian. Throughout the study period, the national Kaiser Permanente guideline on prostate cancer screening recommended a shared decision-making approach in average risk men between the ages of 50 and 69 and in high-risk men between the ages of 45 and 69. The KP guideline was not monitored or enforced and physicians practiced independently. "As seen in this study and others, primary care providers tend to follow USPSTF recommendations," Dr. Presti comments.
After remaining relatively stable from 2007 to 2011, rates of PSA testing decreased starting in 2012, after the USPSTF statement. The decreases in screening were similar across racial groups: between 22 and 25 percent. However, Black men aged 45 to 49 had the largest decrease in screening: about 40 percent.
The three racial groups also had similar and substantial decreases in the rates of prostate biopsy, by 47 to 57 percent (less screening results in fewer elevated PSA levels and thus biopsies); and of the overall prostate cancer detection rate, by 34 to 48 percent (fewer biopsies result in fewer cancers detected). Meanwhile, the rate of metastatic cancer (spread outside the prostate) at diagnosis increased by 39 to 105 percent.
"Even though Black and White men were screened at similar rates in our study, Black men still had higher rates of both local and metastatic prostate cancer," Dr. Presti and colleagues write. "These observations provide opportunity to educate both primary care physicians and patients regarding the importance of screening higher-risk populations."
The researchers emphasize that while their study shows a temporal association, it cannot confirm that the 2012 USPSTF statement caused the reduction in PSA testing. They also acknowledge that some decrease in screening and prostate biopsy may be beneficial: screening can detect slow-growing, "indolent" prostate cancers that would not otherwise cause any symptoms or death – but may cause anxiety in patients, and may also lead to complications related to biopsy for prostate cancer diagnosis.
"Of most concern from the present study is the increased vulnerability of higher-risk cohorts to adverse outcomes, such as higher metastatic cancer, due to reduced screening," Dr. Presti and coauthors conclude. "These data may inform policymakers regarding future changes to prostate-cancer screening recommendations and the shared decision-making process."
DOI: 10.1097/UPJ.0000000000000274
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About Urology Practice
An Official Journal of the American Urological Association (AUA), Urology Practice focuses on clinical trends, challenges and practice applications in the four areas of Business, Health Policy, the Specialty and Patient Care. Information that can be used in everyday practice will be provided to the urology community via peer-reviewed clinical practice articles (including best practices, reviews, clinical guidelines, select clinical trials, editorials and white papers), "research letters" (brief original studies with an important clinical message), the business of the practice of urology, urology health policy issues, urology education and training, as well as content for urology care team members.
About the American Urological Association
Founded in 1902 and headquartered near Baltimore, Maryland, the American Urological Association is a leading advocate for the specialty of urology, and has more than 23,000 members throughout the world. The AUA is a premier urologic association, providing invaluable support to the urologic community as it pursues its mission of fostering the highest standards of urologic care through education, research and the formulation of health care policy. To learn more about the AUA visit: www.auanet.org
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