Major decline in prostate Bx rates follows PSA publications

Badar M. Mian, MD“Journal Article of the Month” is a new Urology Times section in which Badar M. Mian, MD, in which Badar M. Mian, MD (left), offers perspective on noteworthy research in the peer-reviewed literature.  Dr. Mian is associate professor of surgery in the division of urology at Albany Medical College, Albany, NY.

A significant and sustained decrease in prostate biopsy rates has been noted after every major PSA screening publication since the 2008 U.S. Preventive Services Task Force recommendations, according to a study published in European Urology (2017; 71:55-65). The authors report that there has been an overall 33% reduction in the number of prostate biopsies performed in the United States during the study period.

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Lead author Boris Gershman, MD, of Mayo Clinic, Rochester, MN and co-authors performed a retrospective analysis of the administrative claims data in the Optum Labs Data Warehouse, which captures over 100 million enrollees in private health plans and Medicare Advantage plans. There were 104,584 men who underwent initial prostate biopsy between 2005 and 2014. The data included the procedure and diagnosis codes related to insurance claims, as well as comorbidities and pharmacy utilization.

The authors classified the publication of the 2008 USPSTF recommendations, 2009 ERSPC/PLCO trials, 2012 USPSTF recommendations, and 2013 AUA guidelines as an “event” and analyzed the impact of each event on the monthly rates of biopsy and 30-day complication rates. 

After each event, there was significant decrease in the monthly rates of prostate biopsy in the time interval between each event. The largest decrease occurred after the 2012 USPSTF recommendations against PSA screening for all men, followed by 2008 USPSTF recommendations and 2013 AUA guidelines. Of note, the decrease in the monthly biopsy rates was immediate and appeared to be sustained through the study intervals.

As one would expect, fewer biopsies performed resulted in a decrease in total complications, in absolute terms, by 10%. Why was this decrease in complications not proportional to the decrease in the biopsy rates? Because, in relative terms, the 30-day complication rate for men undergoing prostate biopsy actually increased by nearly 28% between 2005 and 2014. This increase in complication rate was driven largely by non-sepsis infections and, to a lesser extent, by sepsis.

There did not appear to be any association between the screening events/publications and increased relative risk of complications. Recent use of fluoroquinolones over the previous 12 months was significantly associated with infectious complications.

Altogether, the recommendations against routine PSA screening did, in fact, lower the number of resultant biopsies and thus have reduced the burden on the health care system by reducing the overall cost and morbidity associated with PSA screening. However, the risk of complications for each individual from each biopsy has increased over the last 10 years.

Next: "This study provides a unique perspective"

While a few other studies have reported a reduction of number of biopsies and a rising risk of post-biopsy complications, this study provides a unique perspective. It represents a large data set that represents most regions of the United States. Further, it’s based on claims data, which makes it more likely to capture the significant complications, use of antibiotics, and comorbidities. However, other clinically important information, such as PSA levels and biopsy results, were not available. Additionally, there is likely an underestimation of certain minor complications (hematuria) that did not generate a claim such as a phone call or nursing care.

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A few interesting questions remain. It’s not clear why the presence of diabetes mellitus did not increase the risk of infectious complications, but the prior use of fluoroquinolones increased the risk of bleeding. Also, the increased risk of non-sepsis complications mostly accounted for the increase in complication rate, but could that be a result of increased awareness and change in antibiotic prescribing behavior rather than a real increase?

It is clear that in order to reduce the morbidity of PSA screening and early detection of prostate cancer, more needs to be done. As the authors point out, continued efforts to reduce the relative risk of complications for each individual are vitally important.

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