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Original Investigation
November 11, 2021

Changes in Prostate-Specific Antigen Testing Relative to the Revised US Preventive Services Task Force Recommendation on Prostate Cancer Screening

Author Affiliations
  • 1Department of Urology, Yale School of Medicine, New Haven, Connecticut
  • 2Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut
  • 3Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
  • 4Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
  • 5Department of Urology, University of California, San Francisco, San Francisco
  • 6Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
  • 7Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
JAMA Oncol. Published online November 11, 2021. doi:10.1001/jamaoncol.2021.5143
Key Points

Question  Was the reversal of the US Preventive Services Task Force (USPSTF) guideline discouraging prostate cancer screening associated with rates of prostate-specific antigen (PSA) testing?

Findings  In this large, national cohort study of privately insured patients (mean bimonthy cohort size of 8 087 565), there was a 12.5% relative increase in rates of PSA testing for men aged 40 to 89 years from 2016 to 2019. Significant increases were seen among patients aged 55 to 69 years, for whom screening is specified by the guideline, but also among those aged 40 to 54 years and those aged 70 years or older, for whom screening is not recommended.

Meaning  Rates of PSA testing increased significantly after the USPSTF’s 2017 draft statement on prostate cancer screening, reversing trends that resulted from earlier guidance.

Abstract

Importance  In April 2017, the US Preventive Services Task Force (USPSTF) published a draft guideline that reversed its 2012 guidance advising against prostate-specific antigen (PSA)–based screening for prostate cancer in all men (grade D), instead endorsing individual decision-making for men aged 55 to 69 years (grade C).

Objective  To evaluate changes in rates of PSA testing after revisions in the USPSTF guideline on prostate cancer screening.

Design, Setting, and Participants  This retrospective cohort study used deidentified claims data from Blue Cross Blue Shield beneficiaries aged 40 to 89 years from January 1, 2013, through December 31, 2019.

Exposures  Publication of the USPSTF’s draft (April 2017) and final (May 2018) recommendation on prostate cancer screening.

Main Outcomes and Measures  Age-adjusted rates of PSA testing in bimonthly periods were calculated, and PSA testing rates from calendar years before (January 1 to December 31, 2016) and after (January 1 to December 31, 2019) the guideline change were compared. Interrupted time series analyses were used to evaluate the association of the draft (April 2017) and published (May 2018) USPSTF guideline with rates of PSA testing. Changes in rates of PSA testing were further evaluated among beneficiaries within the age categories reflected in the guideline: 40 to 54 years, 55 to 69 years, and 70 to 89 years.

Results  The median number of eligible beneficiaries for each bimonthly period was 8 087 565 (range, 6 407 602-8 747 308), and the median age of all included eligible beneficiaries was 53 years (IQR, 47-59 years). Between 2016 and 2019, the mean (SD) rate of PSA testing increased from 32.5 (1.1) to 36.5 (1.1) tests per 100 person-years, a relative increase of 12.5% (95% CI, 1.1%-24.4%). During the same period, mean (SD) rates of PSA testing increased from 20.6 (0.8) to 22.7 (0.9) tests per 100 person-years among men aged 40 to 54 years (relative increase, 10.1%; 95% CI, −2.8% to 23.7%), from 49.8 (1.9) to 55.8 (1.8) tests per 100 person-years among men aged 55 to 69 years (relative increase, 12.1%; 95% CI, −0.2% to 25.2%), and from 38.0 (1.4) to 44.2 (1.4) tests per 100 person-years among men aged 70 to 89 years (relative increase, 16.2%; 95% CI, 4.2%-29.0%). Interrupted time series analysis revealed a significantly increasing trend of PSA testing after April 2017 among all beneficiaries (0.30 tests per 100 person-years for each bimonthly period; P < .001).

Conclusions and Relevance  This large national cohort study found that rates of PSA testing increased after the USPSTF’s draft statement in 2017, reversing trends seen after earlier guidance against PSA testing for all patients. Increased testing was also observed among older men, who may be less likely to benefit from prostate cancer screening.

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    1 Comment for this article
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    Interpretation of USPSTF statement, current Prostate specific antigen screening is a continuation of “Bowery series”.
    Takeshi Takehashi, M.D, Ph.D | Health and Welfare bureau, Kitakyushu city
    Leapman et al. are trying to create the story, "The USPSTF corrected the 2012 misjudgment in 2018. Urologists worked hard to correct the wrong trends."1 Urologists have criticized the USPSTF and are trying to further promote PSA screening. However, their criticism is based on misunderstandings about overall survival and overdiagnosis.2,3 These misconceptions are caused by “Hudson Dogma”.

    Dr. Perry Hudson was a conductor of unethical medical practice in 1950’s called Bowery series; performed on more than 1200 alcoholic men recruited from homeless shelters.4 He asked a pathologist to develop pathological criteria for diagnosing early-stage cancer in order to determine
    the indications for prostatectomy. The criteria (the absence of basal cells, prominent nucleoli, and small acinar formation) were merely morphological observation of a pathologist5 and have not been scientifically validated. However, the criteria seemed to justify Hudson’s dogma, "Pathological tests can detect early-stage prostate cancer and it can be treated by surgery”.4, 5 Hudson has quit the series, warned of lawsuit. But, when PSA, ultrasound and needle biopsy emerged in the 1990s, pathologists adopted the criteria without mentioning historical background or scientific validity and confused the issue using Gleason scores.4, 6 Since then, both urologists and pathologists have conducted various studies on limited endpoints (e.g., improved case fatality, post-treatment PSA determinations), with no appropriate control group.3 These studies formed a self-reinforcement cycle, and the Hudson dogma became more illusioned as being established. USPFTF listed only three RCTs as evidence to validate the benefits of PSA screening, while excluded these studies, and states that the benefit is uncertain and there is the problem of overdiagnosis, which implies that neither Hudson dogma nor the criteria are true. The USPSTF has changed Grade D to C, but what they says hasn't changed at all. Current PSA screening is a continuation of the Bowery series. The key factor of overdiagnosis is pathological diagnosis.

    In the pathological diagnosis of other types of cancer, there is supportive evidence such as the formation of tumors and the establishment of cell lines, but not in prostate cancer. Also, due to the extremely low cancer mortality rate, the benefits of screening, if any, are so small that it requires heroic effort to show statistically. Pathologists should change the diagnosis name “prostate cancer” to IDLE,7 "a pathological entity formerly known as early prostate cancer” or something else. REFERENCE

    1. Leapman MS, et al. JAMA Oncol. 2021:e215143. doi: 10.1001/jamaoncol.2021.5143.
    2. Takahashi TF. The golden rule: Do not do to others what you do not want done to yourself. Cancer. Cancer. 2020;126(10):2319-2320.
    3. Takahashi T. Would You Play a Russian Roulette-type Game of Prostate-specific Antigen Screening on Yourself? Eur Urol. 2021:S0302-2838(21)02071-6. doi: 10.1016/j.eururo.2021.10.003.
    4. Aronowitz R. "Screening" for prostate cancer in New York's skid row: history and implications. Am J Public Health. 2014;104(1):70-6.
    5. Totten RS. Some experiences with latent carcinoma of the prostate. Bull N Y Acad Med. 1953;29(7):579-82.
    6. Young RH, The history of urologic pathology: an overview. Histopathology. 2019;74(1):184-212.
    7. Esserman LJ, et al. Addressing overdiagnosis and overtreatment in cancer: a prescription for change. Lancet Oncol. 2014 May;15(6):e234-42.
    CONFLICT OF INTEREST: None Reported
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