AUA, others fight measure penalizing docs who order PSA

Dec 09, 2015

The proposed clinical quality measure comes as a pair of JAMA studies note a decline in screening since the USPSTF recommended against screening.

A recent proposed clinical quality measure titled “Non-Recommended PSA-Based Screening” has drawn concern and opposition from the AUA, the American Medical Association, individual urologists, and other physicians. 

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The quality measure, developed by Mathematica Policy Research for the Centers for Medicare & Medicaid Services (CMS), comes on the heels of two newly published studies noting declines in PSA screening since the U.S. Preventive Services Task Force (USPSTF) 2012 grade D recommendation against screening.

The measure “discourages PSA screening in all men over age 18, regardless of age or risk factors,” according to a Nov. 18 article in the AUA’s Policy & Advocacy Brief.

The AMA is standing with the AUA in its opposition to the measure, according to the AUA.

Also see: Can Gleason 7 cancer be low-risk disease?

If passed, urologists would be indirectly impacted, with patients and primary care providers being most affected, according to AUA Public Policy Council Chair David F. Penson, MD, MPH, of Vanderbilt University Medical Center, Nashville, TN.

Next: Dr. Penson discusses how measure would impact providers

 

“This measure is really geared toward primary care providers,” Dr. Penson told Urology Times. “Simply put, they would be considered ‘low quality’ providers if they performed PSA screening/testing in any man in their practice who did not have a known diagnosis of prostate cancer. This, in turn, would affect their reimbursement directly, as they could potentially be penalized in the new [Medical Expenditure Panel Survey] MEPS program.

Read: New PCa test outperforms PSA in men with Gleason ≥7 disease

“The impact on urologists would be more indirect. The primary care disincentive to screening would result in further reduction in prostate cancer incidence rates in the short term. In the long term, once incidence rates leveled off, we would likely see an increase in the proportion of patients presenting with advanced disease. Ultimately, we will see an increase in prostate cancer mortality, as well. This is obviously bad for our patients.”

In a document about the measure, Mathematica cited the USPSTF’s review of PSA-based screening evidence that concluded that screening does more harm than good.

“False-positive results from PSA tests are relatively common, meaning that PSA tests identify some men without cancer,” Mathematica wrote. “PSA-based screening can also lead to detection of asymptomatic conditions that would have caused no morbidity during a patient’s lifetime. For these reasons, men with a positive result on a PSA-based screening might receive unnecessary diagnostic testing or treatment-procedures with risks of complications, including urinary incontinence, erectile dysfunction, or serious cardiovascular events.”

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In its grade D recommendation, USPSTF recommends against PSA-based screening for prostate cancer among men, regardless of age. Men excluded from the recommendation include those with a prostate cancer history or diagnosis; a diagnosis of dysplasia of the prostate during the measurement year or the year prior to the measurement year; an elevated PSA test result in the year prior to the measurement period (>4.0 ng/mL); or those being prescribed a 5-alpha reductase inhibitor during the measurement year, according to USPSTF.

Next: Drs. Kutikov, Cooperberg comment on measure

 

The AUA encouraged its members to submit public comments to CMS regarding the quality measure. Among those who commented was Alexander Kutikov, MD, of Fox Chase Cancer Center, Philadelphia.

“As a urologic oncologist who believes PSA is overused and prostate cancer is often overtreated, I firmly believe that penalizing physicians for PSA screening throws out the proverbial baby with the bath water. I hope that the screening debate and screening policies can be decided using less drastic measures than the one proposed,” Dr. Kutikov wrote.

In his public comment on the measure, Matthew R. Cooperberg, MD, MPH, noted that the USPSTF’s is the only recommendation against all screening, whereas other groups such as the AUA and National Comprehensive Cancer Network “recommend some variation on shared decision-making recognizing both benefits and harms of screening.”

“To establish a CQM (clinical quality measure) on this issue suggests that consensus exists where in fact a raging controversy continues... PSA screening should be improved not abandoned, and this CQM would be a major step in the wrong direction, and exactly the wrong time,” said Dr. Cooperberg, of the University of California, San Francisco.

In discussing his opposition to the USPSTF recommendation, Dr. Penson said the panel’s recommendation has had a negative impact on screening.

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“I feel as though the USPSTF has selectively looked at the data and reached the wrong conclusion. I agree with the recent AUA guidelines on prostate cancer detection [and] would endorse shared decision making around prostate cancer screening,” Dr. Penson said. “We have already seen a drop in the incidence of prostate cancer, so the USPSTF recommendation has negatively affected screening, already.”

Next: JAMA studies look at changes in screening, PCa incidence

 

In fact, two recent JAMA studies looked at the change in PSA screening and prostate cancer incidence before and after the 2012 recommendation.

“Both the incidence of early-stage prostate cancer and rates of PSA screening have declined and coincide with 2012 USPSTF recommendation to omit PSA screening from routine primary care for men,” wrote the authors of one study, led by Ahmedin Jemal, DVM, PhD, of the American Cancer Society, Atlanta (JAMA 2015; 314:2054-61).

In the other study, researchers looked at PSA screening data from the 2000, 2005, 2010, and 2013 National Health Interview Survey to determine the prevalence and determinants of screening before and after the 2012 USPSTF recommendations, as well as the association between the new USPSTF recommendations and the prevalence of screening, according to a JAMApress release(JAMA 2015; 314:2077-79).

“The 2008 USPSTF recommendations against PSA screening in men aged 75 years or older have not been associated with changes in screening practices. However, we found a decrease in the prevalence of PSA screening following the 2012 recommendations, particularly in men younger than 75 years,” wrote the authors, led by Jesse D. Sammon, DO, of Henry Ford Health System, Detroit.

It’s hard to say what comes next, but urologists and their patients can and should speak up, according to Dr. Penson.

“We have already seen a drop in the incidence of prostate cancer, so the USPSTF recommendation has negatively affected screening, already,” Dr. Penson said. “This quality measure will just [discourage] primary care providers further. Urologists need to be vocal in their opposition to this measure. They need to let their patients and their elected officials know about this misguided measure, so that they can be vocal, as well.”

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