Sharp drop in prostate cancer procedures after PSA screening curb

By David Douglas

NEW YORK (Reuters Health) - Since guidelines recommended a halt to population-based prostate specific antigen (PSA) screening, there has been a significant drop in the volume of prostate biopsy and radical prostatectomy, according to researchers.

The U.S. Preventive Services Task Force (USPSTF) recommended against routine PSA screening in 2012.

Dr. Jim C. Hu, who led the new study, told Reuters Health by email, "As a prostate cancer expert, I have anecdotally seen a decrease in the volume of patients referred to me for prostate cancer. Therefore the goal of our study was to examine nationally the influence of the guideline recommendations on clinical practice and we were startled by the rapidity of the decline in the procedural volume of prostate biopsy and radical prostatectomy."

As reported November 2 online in JAMA Surgery, Dr. Hu of New York Presbyterian/Weill Cornell, New York City and colleagues examined operative case logs from 2009 through 2016, from a nationally representative sample of urologists. In all, 5173 urologists performed at least one prostate biopsy and 3748 performed at least one radical prostatectomy.

After the recommendations, the median biopsy volume per urologist fell from 29 to 21. After adjustment, this amounted to a 28.7% drop. Similarly, the median radical prostatectomy volume fell from 7 to 6, a reduction of 16.7% after adjustment.

But despite the overall drop in the number of prostate biopsies performed following the 2012 recommendation, "we see that a growing component of biopsies performed is to monitor men on active surveillance," Dr. Hu said.

The volume of these procedures rose from 597 to 769 during the study period, a 28.8% increase.

"I believe," he added, "that PSA screening is an individualized choice with evidence showing benefit under certain circumstances, and the concern is that this rapid drop in the diagnosis and treatment of prostate cancer may reverse the decline in prostate cancer metastases and death seen since the early 1990s when PSA was widely adopted."

Summing up, Dr. Hu concluded that the "most recent evidence demonstrates that more physicians and men are adopting active surveillance without rushing to treatment and (with an understanding of) the indolent nature of low-risk disease. Therefore, do the ills of over-diagnosis and over-treatment still apply in light of improved patient education and health literacy?"

Commenting by email, Dr. Pauline Filippou of The University of North Carolina at Chapel Hill, co-author of an accompanying editorial, told Reuters Health, "As a community we didn't expect to see declining rates of these procedures in conjunction with decreased PSA testing only several years following the USPSTF recommendation change."

She continued, "There is concern within the urologic community that the slow-growing and indolent nature of prostate cancer will delay the observation of the negative downstream effects of decreased prostate cancer screening rates until it's too late."

According to Dr. Filippou, the trial supporting the USPSTF recommendation "was poorly designed, and other similar, higher quality trials have shown that PSA screening decreases overall prostate cancer morbidity and mortality."

"What we don't wish to see," she concluded, "is a return to the relatively higher mortality observed for prostate cancer patients that existed before widespread PSA screening."

SOURCE: https://bit.ly/2es1YYw and https://bit.ly/2fMmENx

JAMA Surg 2016.