“Both physicians and patients should take into account remaining life expectancy before adopting screening pathways,” a study author says.
About 16% of people age 65 years and older who, according to guidelines, should not be screened for prostate and breast cancer because of their limited life expectancy, may have received the screenings anyway, according to a research letter published online in JAMA Oncology (Jan. 21, 2016).
Researchers from several institutions studied data from 149,514 U.S. adults who were 65 years of age or older and responded to the Behavioral Risk Factors Surveillance System survey in 2012. Among those, 76,419, or 51.1%, had a PSA test or mammography in the last year; 23,532 patients, or 30.8%, had a life expectancy of less than 10 years. Those figures correspond to an overall rate of non-recommended screening of 15.7%, according to a press release from JAMA Oncology.
Non-recommended PSA screening varied by state. Georgia had the highest rate, at an average 26.9%. Kansas followed at 23.3% and Missouri at 23.1%, according to lead study author Firas Abdollah, MD, of Henry Ford Hospital, Detroit, who worked on the study with Quoc-Dien Trinh, MD, and co-authors. Both Dr. Abdollah and Dr. Trinh are urologists.
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“We know from the current study that the rates of non-recommended PSA screening vary by more than 200% between states (from 13.1% in Vermont to 26.9% in Georgia). Unfortunately, we don’t exactly know how many urologists are suggesting non-recommended PSA screening,” Dr. Abdollah said.
Urologists, in general, may not be primarily responsible for these findings because most prostate cancer screening is performed by primary care physicians, according to Urology Times Editorial Council member Stacy Loeb, MD, MSc, of New York University School of Medicine, New York. Dr. Loeb, who was not involved with the research letter, cited a study published June 2014 in the Journal of Urology that suggests urologists perform only about 6% of PSA screenings in the U.S. That’s compared to 64.9% performed by internal medicine physicians and 23.7% performed by family physicians.
In fact, a lot has changed since 2012, according to Dr. Loeb.
“We know that rates of PSA screening and prostate biopsy in this country have decreased since the [U.S. Preventive Services Task Force] issued a Grade D recommendation against screening in 2012,” Dr. Loeb said. “I expect that if this study were repeated today (in 2016), the rates of inappropriate testing would be lower. Certainly in the urological community, we have become much more selective about who we screen, who we biopsy, and who gets treated for prostate cancer.”
“PSA screening for prostate cancer is intended to detect prostate cancer at a stage where early treatment is likely to increase the chances of survival and reduce the need for secondary treatments down the line,” Dr. Abdollah said. “However, definitive treatment, either by radical prostatectomy or radiation therapy, has consequent morbidities (such as erectile dysfunction), which may adversely affect a patient’s quality of life.”
The decision to initiate or continue PSA screening should be contingent on two principles, according to Dr. Abdollah: a clear discussion of the risks and benefits associated with PSA screening, and shared decision making, taking into account the patient’s personal preferences. And PSA screening should generally be avoided in patients with limited remaining life expectancy of less than 10 years because, even if these men are diagnosed with prostate cancer, they are likely to outlive their disease and will not benefit from aggressive treatment.
Most major professional guidelines recommend against screenings for people with limited life expectancy, including the AUA, American Cancer Society, American College of Physicians, and American Society of Clinical Oncology, according to Dr. Abdollah.
Dr. Abdollah offered this example of an over-diagnosis: performing a PSA screening in an 83-year-old man with multiple comorbidities, diagnosing a Gleason 3+3 prostate cancer on prostate biopsy, and treating with robot-assisted radical prostatectomy or intensity-modulated radiation therapy.
“Prior research has shown that the use of these advanced treatment technologies in men with low-risk disease and high risk of dying due to non-cancer causes increased significantly from 25% to 34% between 2005 and 2009,” Dr. Abdollah said. “The mean incremental cost of these technologies extrapolates to $282 million and $4 million respectively (for the year 2005).”
The 40% concordance between breast and prostate screening suggests that states that were more likely to perform non-recommended breast cancer screening were more likely to perform non-recommended prostate cancer screening, as well.
“Although we cannot know the exact reasons for this association based on our data, possible reasons include similar diagnostic and treatment patterns of physicians in a given state, patient expectations, or reimbursement of screening services by state-specific insurance agencies,” Dr. Abdollah said. “Regardless, this remains an active area of investigation.”
“The most important message that we seek to highlight is that both physicians and patients should take into account remaining life expectancy before adopting screening pathways,” Dr. Abdollah said. “Novel life expectancy calculator tools (like the one used in a study by Cho et al) can help in this assessment.”
It is essential that urologists educate primary care physicians on the risks and benefits of prostate cancer screening, including appropriate patient selection, according to Dr. Loeb.
“As urologists, we receive consults for elevated PSA levels in men who were screened inappropriately. The key take-home message for urologists in this situation is that screening, biopsy, and treatment all represent distinct decision points. Therefore, it is our responsibility to counsel these patients on the benefits and harms of pursuing further diagnostic workup based on that PSA level in conjunction with their general health status and preferences,” Dr. Loeb said.
It’s noteworthy, according to Dr. Loeb, that several new markers are now available that can be used as reflex tests to help decide on prostate biopsy for men with PSA levels >3.0 ng/mL, and magnetic resonance imaging technology has improved significantly.
“There have also been positive changes in treatment trends in the past few years, including a dramatic increase in the use of active surveillance,” Dr. Loeb said. “Overall, there have been great advances in the past few years in an effort to maximize the benefits and reduce the downstream harms of screening.”
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