PSA testing in the “real world” … from 2010 to 2015

A newly published article in the journal Cancer suggests that, in fact, the USPSTF guidance on use of the PSA test for risk of prostate cancer has had little impact in the “real world” between 2010 and 2015 (at least at one large tertiary care institution in Texas).

This article by Hutchinson et al. used data from a the electronic medial records of the University of Texas Southwestern Medical Center (UTSMC) in Dallas, TX, to track PSA orders and urology referrals from January 2010 to July 2015. It is also discussed in a media release issued by UTSMC that is also published on the ScienceDaily web site.

In this study, PSA tests were defined as “screening” tests only when they had been ordered by physicians in the departments of internal medicine, family medicine, or general internal medicine (i.e., primary care physicians at UTSMC).

Here are the core study findings:

  • Between January 2010 and July 2015, there were
    • 275,784 unique ambulatory visits for male patients.
    • 63,722 raw PSA orders, of which 54,684 were evaluable.
  • Primary care physicians ordered 17,315 PSA tests and made 858 referrals to UTMSC urologists.
  • Over the 5.5-year time period there were no significant changes in
    • The number of PSA tests per ambulatory visit
    • The number of referrals per ambulatory visit
    • The ages of patients at the time of the urology referral
    • The proportion of PSA tests performed outside the recommended age range
  • There was a small but statistically significant increase (P = 0.022) in the PSA value at the time of referral.

Alas, neither the abstract of this paper nor the media release tell us exactly how small (or large) the (presumably) average increase in the PSA value was over the years.

The authors conclude that, in the years surrounding the USPSTF recommendation,

  • PSA behavior did not change significantly, and
  • Patients were referred at progressively higher average PSA levels, but
  • The slightly higher PSA levels probably had little clinical impact on treatment or results.

Now it will be obvious that these are data from “just one center”, but on the other hand they do also suggest that the primary care community at that center has continued to carry out PSA testing with a similar frequency both before and after the issuance of the USTSPF guidelines.

The question of the “real” effect of the USPSTF guidance on prostate cancer “screening” using the PSA test is still not well resolved, and with the USPSTF in the middle of a new review of its guidance, the current situation may turn out to be moot anyway. We are currently expecting an initial draft of the new USPSTF guidance some time in 2017, but we have no exact date for this.

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