Recent Patterns of Prostate-Specific Antigen Testing for Prostate Cancer Screening in the United States

Recommendations for prostate-specific antigen (PSA)-based prostate cancer screening have changed considerably in recent years. In 2008, the US Preventive Services Task Force (USPSTF) recommended against PSA-based prostate cancer screening among men 75 years or older, and in 2012, they recommended against PSA testing for men of all ages.¹ Other organizations emphasize shared-decision making for men 50 years or older with a long life expectancy.² As a result of shifting recommendations, PSA screening rates declined from 37.8% in 2010 to 30.8% in 2013 among men 50 years or older, resulting in substantial declines in prostate cancer incidence.³ However, it is not known if PSA testing has continued to decline. The objective of the present study was to examine PSA testing patterns using recently released 2015 National Health Interview Survey (NHIS) data.

Data on 19 690 male respondents 50 years or older were selected from the 2010, 2013, and 2015 NHIS, an in-person household survey of noninstitutionalized people with respective response rates of 60.8%, 61.2%, and 55.2%.⁴ The primary outcome was self-reported PSA testing in the past year for routine reasons. Men who reported a history of or were missing data on prostate cancer diagnosis (n = 1115) or PSA testing (n = 1574) or who had PSA testing for nonscreening reasons (n = 805) were excluded, resulting in an analytic population of 16 196 men. The χ² test (α = .05) was used to examine differences in PSA screening rates (SRs). Adjusted screening rate ratios (SRRs) and corresponding 99% confidence intervals (CIs) were estimated using logistic regression models with predicted marginal probabilities and controlled for sociodemographic factors, insurance, and health care characteristics. All analyses were conducted using SAS-callable SUDAAN software, version 9.4, and accounted for the complex survey design.

Of the 16 196 men included in our analyses, more than half were aged 50 to 64 years, and three-quarters had visited their primary care physician in the past year, proportions that were similar across survey years. Among men 50 years or older, unadjusted SRs of PSA testing for routine reasons in the past year decreased from 38.3% in 2010 to 31.5% in 2013 (P < .001) and remained stable at 32.1% through 2015 (P = .62) (Table 1). Adjusted analyses were similar where the PSA testing in the past year was significantly lower in 2013 than in 2010 (SRR, 0.83; 99% CI, 0.77-0.89) but not significantly different in 2015 and 2013 (SRR, 0.99; 95% CI, 0.91-1.08). The pattern of declining PSA testing between 2010 and 2013, but not between 2013 and 2015, was similar across age groups (50-64, 65-74, and ≥75 years) (Table 1 and Table 2).

In this nationally representative study, we found that previously reported declines in PSA testing have not continued in recent years, and approximately a third of men 50 years or older still receive routine PSA testing. Physicians interested in deadopting PSA testing may have done so, closely following the USPSTF recommendation and the media attention that came with it. In addition, other public health organizations still support PSA testing,² albeit with shared decision making, and physicians may have chosen to continue to offer PSA testing based on their beliefs about screening and interpretation of clinical trial results. We relied on self-reported PSA testing, which is subject to recall bias, and some men may not have been informed of testing, which is a limitation of the study.⁵ However, this study provides data on contemporary nationwide PSA testing patterns.

In conclusion, previous declines in routine PSA testing between 2010 and 2013 did not continue in the most recent time period (between 2013 and 2015). A recent study reported a modest short-term (from 2011-2013) increase in the incidence of metastatic prostate cancer among men 75 years or older.⁶ However, continued evaluation on how testing patterns influence prostate cancer outcomes over the long term are needed.

Corresponding Author: Stacey A. Fedewa, PhD, Surveillance and Health Services Research, American Cancer Society, 250 Williams St NW, Atlanta, GA 30303 (stacey.fedewa@cancer.org).

Published Online: April 24, 2017. doi:10.1001/jamainternmed.2017.0340

Author Contributions: Dr Fedewa had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: Fedewa, Brawley, Jemal.

Drafting of the manuscript: Fedewa, Brawley.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Fedewa, Brawley.

Administrative, technical, or material support: Fedewa.

Supervision: Fedewa, Jemal.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by the American Cancer Society.

Role of the Funder/Sponsor: Staff members of the Surveillance and Health Services Research Program of the American Cancer Society played a role in the design and conduct of the study; and collection, management, analysis, and interpretation of the data. No staff members at the American Cancer Society, other than the study authors, played any role in the preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.