Prostate-Specific Antigen Screening After 2012 US Preventive Services Task Force Recommendations

Prostate-specific antigen (PSA) screening is a widely debated practice in the United States, given that PSA screening can lead to the diagnosis of nonlethal prostate cancer and the harms associated with treatment of such disease.¹ In this context, the 2008 US Preventive Services Task Force (USPSTF) panel recommended against PSA screening in men older than 75 years. This recommendation, however, has been ineffective at reducing the observed prevalence of PSA screening among older men.² More recently, the USPSTF issued a grade D recommendation against PSA screening for all men, regardless of age.³

We examined PSA screening data from the 2000, 2005, 2010, and 2013 National Health Interview Survey (NHIS) to determine the prevalence and determinants of screening before and after the 2012 USPSTF recommendations (draft released October 2011), as well as the association between the new USPSTF recommendations and the prevalence of screening. The NHIS is an in-person household survey, with multistage area probability sampling providing a representative sample of the US population; survey response rates were approximately 80%. This study received a waiver of institutional review board approval by the Brigham and Women’s Hospital institutional review board.

Males aged 50 years or older who reported PSA testing within the 12 months preceding each year’s survey were considered to have undergone screening. Exclusions included a history of prostate cancer and the answer “because of a problem” or “other reason,” in response to the question, “What was the main reason you had this PSA test—was it part of a routine exam, because of a problem, or some other reason?”

We examined the prevalence of screening in all survey years and tested the association between survey year and the odds of screening before vs after the 2012 USPSTF recommendations with complex-sample logistic regression models (adjusted for race/ethnicity, region, marital status, educational attainment, insurance status, smoking status, household income, health care use, and personal health status). Pooled analyses of 2010 and 2013 survey data were first performed in the populations aged 75 years or older and in those younger than 75 years and a difference-in-differences analytic approach⁴ was then used to evaluate whether the 2012 USPSTF recommendations were associated with a decrease in PSA screening in men younger than 75 years. Those aged 75 years or older were subject to previous recommendations against PSA screening and served as a control population. Results were weighted to reflect the US population based on the complex survey design.

Statistical analyses were performed with SPSS version 21 (SPSS Inc). A 2-sided P value <.05 was the threshold for statistical significance.

The final study population included 20 757 men (4698 in 2000, 5111 in 2005, 4598 in 2010, and 6350 in 2013). The prevalence of PSA screening was 34% (95% CI, 33%-36%) in 2000 and 2005. Between 2010 and 2013, the prevalence decreased from 36% (95% CI, 34%-37%) to 31% (95% CI, 30%-33%) overall. In a pooled analysis, survey year 2013 (vs 2010) was associated with lower odds of PSA screening (odds ratio [OR], 0.79 [95% CI, 0.71-0.88]) (Table).

However, declines were seen only in men younger than 75 years (OR, 0.78 [95% CI, 0.70-0.88] vs men ≥75 years OR, 0.85 [95% CI, 0.66-1.10]). The largest declines were seen among men aged 50-54 years (from 23% [95% CI, 20%-26%] to 18% [95% CI, 15%-21%]; OR, 0.71 [95% CI, 0.56-0.91]) and among men aged 60-64 years (from 45% [95% CI, 41%-49%] to 35% [95% CI, 32%-39%]; OR, 0.69 [95% CI, 0.54-0.89]).

After adjusting for patient factors, there were significant reductions in PSA screening associated with the 2012 USPSTF recommendations (difference-in-differences P < .001; Figure).

The 2008 USPSTF recommendations against PSA screening in men aged 75 years or older have not been associated with changes in screening practices.^2,5 However, we found a decrease in the prevalence of PSA screening following the 2012 recommendations, particularly in men younger than 75 years.

These findings using nationally representative data suggest that younger men may be altering health care behavior at a higher rate than older men following the new USPSTF recommendations, changes in clinician PSA screening practices have occurred in response to the policy change, or both. Alternatively, the findings may reflect the broad effects of the economic recession on health care use or a delayed response to the 2008 guidelines.

Limitations of this study include relying on a single year of data after the USPSTF recommendations; nonresponse, recall and social desirability biases; limited regression model goodness of fit; and the inherent limitations of the difference-in-differences study design.⁴

Corresponding Author: Jesse D. Sammon, DO, Brigham and Women’s Hospital, 45 Francis St, Boston, MA 02115 (jsammon@partners.org).

Author Contributions: Drs Sammon and Trinh had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Sammon, Abdollah, Menon, Trinh.

Acquisition, analysis, or interpretation of data: Sammon, Abdollah, Choueiri, Kantoff, Nguyen, Trinh.

Drafting of the manuscript: Sammon, Abdollah, Trinh.

Critical revision of the manuscript for important intellectual content: Abdollah, Choueiri, Kantoff, Nguyen, Menon, Trinh.

Statistical analysis: Sammon, Abdollah, Trinh.

Administrative, technical, or material support: Sammon, Choueiri, Kantoff, Nguyen, Menon.

Study supervision: Choueiri, Menon, Trinh.

Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Funding/Support: Dr Trinh is supported by an unrestricted educational grant from the Vattikuti Urology Institute and the Professor Walter Morris-Hale Distinguished Chair in Urologic Oncology at Brigham and Women’s Hospital.

Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank Gally Reznor, MSc (Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts), and Mireya Diaz, PhD (VUI Center for Outcomes Research, Analytics and Evaluation, Henry Ford Health System, Detroit, Michigan), for their review of the statistical methods for which no specific compensation was received.