Investigators recently examined prostate cancer screening among primary care providers and found that screening tests were frequently used—even when they provide little value to patients, according to a new study published by Gillette et al in the Journal of the American Board of Family Medicine.
Background
Prostate cancer is responsible for over 34,000 deaths in the United States each year, according to the American Cancer Society. However, guidelines for prostate cancer screening are continually shifting, leading to uncertainty among patients and providers on when and if screening tests should be ordered. The current screening guidelines recommend that providers discuss the benefits and risks of prostate cancer screening for male patients aged 55 to 69 years.
“Screening is complex because while some prostate cancers are aggressive, most grow slowly and may never cause symptoms or death,” explained principal study investigator Chris Gillette, PhD, Associate Professor of Physician Assistant Studies as well as Epidemiology and Prevention at Wake Forest University School of Medicine.
Providers typically use one of two tests to help diagnose prostate cancer: a digital rectal exam and a prostate-specific antigen (PSA) blood test. However, these screening tools often lead to false-positive results and can put the patient at risk for an increased likelihood of overdiagnosis as well as more aggressive testing that might result in harm with little to no benefit.
“As [male patients age], the risk for a false-positive result increases,” noted Dr. Gillette, pointing out that “[Male patients] who are 70 years and older are at the highest risk for overdiagnosis.”
In 2012, the U.S. Preventive Services Task Force recommended against any PSA-based screening in male patients, but changed their recommendation in 2018 to not screen male patients aged over 70 years. In 2013, the American Urological Association also recommended against PSA-based prostate cancer screening for male patients aged over 70 years.
Investigation Methods and Findings
For this study, Dr. Gillette and his colleagues conducted a secondary analysis of the National Ambulatory Medicare Care Survey datasets from 2013 to 2016 and 2018. The data set is a nationally representative sample of visits to nonfederal, office-based physician clinics.
In looking at primary care visits for male patients aged over 70 years, the investigators found 6.71 PSA tests and 1.65 digital rectal exams per 100 visits. The investigators restricted their analysis to primary care providers and those patients without any clear medical history that would necessitate a PSA test or digital rectal exam as a diagnostic test.
“We also found that providers who order a lot of tests are more likely to order low-value screening[s] such as [PSA tests and digital rectal exams],” Dr. Gillette revealed.
Specifically, for each service ordered, there was a 49% increase in the odds that a patient would undergo a low-value PSA test and a 37% increase in the odds that a patient would undergo a low-value digital rectal exam.
Conclusions
The investigators hypothesized that providers might be responding to patient requests when ordering these screening tests or using what’s known as a “shotgun” approach to medical testing—where all possible tests are ordered during a medical visit.
“However, as health-care systems move toward a more value-based care system—where the benefit of services provided outweighs any risks—providers need to engage patients in these discussions on the complexity of this testing,” stressed Dr. Gillette, concluding that “Ultimately, when and if to screen is a decision best left between a provider and the patient.”
Disclosure: For full disclosures of the study authors, visit jabfm.org.
