Prostate Biopsies and Surgeries Seen to Fall in US After PSA Screening Found Wanting

Prostate Biopsies and Surgeries Seen to Fall in US After PSA Screening Found Wanting
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The number of prostate biopsies and surgeries (radical prostatectomy, or RP) prescribed by doctors to diagnose and treat prostate cancer has dropped significantly since 2012, when a U.S. task force recommended against prostate-specific antigen (PSA) screening for this cancer, according to a study published in JAMA Surgery.

The study, “National Trends in Prostate Biopsy and Radical Prostatectomy Volumes Following the United States Preventative Services Task Force Guidelines Against Prostate-Specific Antigen Screening,” is timely, its researchers said, as the task force recommendation is being reconsidered.

In the 1990s, the United States implemented several screening programs for prostate cancer, based on the high incidence of this type of cancer and its high potential cure rate when detected in time.

But some four years ago, the U.S. Preventative Services Task Force (USPSTF) discouraged PSA screening after a randomized clinical trial showed it of no benefit to mortality rates. PSA-based screening decreased significantly following this recommendation. Few studies since, however, have examined the recommendation’s direct impact on diagnostic and therapeutic prostate cancer practices.

Researchers analyzed the practice patterns of certifying and recertifying urologists, from 2009 through 2016, looking for changes in the number of prostate biopsies and RP procedures prescribed. The study included a representative sample of urologists across practice settings, and a nationally representative sample of all RP discharges from hospitals.

Analysis indicated that, following the USPSTF recommendation, the median biopsy volume per urologist decreased from 29 to 21. Moreover, after adjusting for physician and practice characteristics, biopsy volume decreased by about 29 percent after 2012.

The total number of annual biopsies also decreased by 12.7 percent. The greatest drop was seen in biopsies performed in response to an abnormal PSA (26.7 percent), while the number of prostate biopsies done due to an indication of cancer increased by 28.8 percent during the study period.

“We demonstrate changing trends in the indications for prostate biopsy, with fewer patients undergoing this procedure for abnormal PSA,” Joshua Halpern, with Weill Cornell Medicine, and colleagues wrote. “This finding strengthens the associational relationship found in prior studies insofar as it directly links decreased PSA testing with biopsy volume. In contrast, the number of biopsies performed for active surveillance of prostate cancer has increased, consistent with studies demonstrating an uptake in observation of men with low-risk prostate cancer.”

The median RP number per urologist also decreased from 7 to 6, and in the adjusted analyses, that number fell by 16 percent.

“Experts have expressed concern regarding the long-term effect of the USPSTF recommendation on prostate cancer-specific morbidity and mortality in the United States,” the researchers wrote. “This concern is reinforced by the findings of this study demonstrating that decreased prostate cancer screening has been accompanied by a downtrend in diagnostic and therapeutic procedures for prostate cancer.”

Although these findings raise important questions regarding the long-term effects of such reductions, particularly concerning the cancer-related morbidity and mortality, the researchers note that it might be too early to determine the full consequences of the 2012 recommendation.

“[G]iven that lead time associated with PSA screening is estimated at 5 to 7 years and the indolent nature of prostate cancer, a resultant increase in prostate cancer–specific mortality would likely remain undetectable for another decade,” they wrote. “Thus, longer-term population-based studies will be necessary to determine the true effect of the USPSTF recommendation on prostate cancer–specific mortality.”

Still, they added, “Because revision of the USPSTF recommendation is in progress, policy makers should weigh the downstream effects of the 2012 USPSTF recommendation and consider future unintended consequences.”

 

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