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The Roles of Providers and Patients in the Overuse of Prostate-Specific Antigen Screening in the United States

Fangjian Guo, MD, PhD; and Di He, MS
[+] Article, Author, and Disclosure Information

From Center for Interdisciplinary Research in Women's Health, The University of Texas Medical Branch, Galveston, Texas; and David Eccles School of Business, The University of Utah, Salt Lake City, Utah.

Note: All data from NHANES (National Health and Nutrition Examination Survey) used in this study were collected by the National Center for Health Statistics for the Centers for Disease Control and Prevention.

Disclaimer: The findings and conclusions in this article are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention, National Center for Health Statistics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, or National Institutes of Health.

Primary Funding Source: Dr. Guo is currently supported by an institutional training grant (National Research Service Award T32HD055163) from the Eunice Kennedy Shriver National Institute of Child Health and Human Development at the National Institutes of Health.

Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterest Forms.do?msNum=L15-0220.


Ann Intern Med. 2015;163(8):650-651. doi:10.7326/L15-5150
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Patient-initiated prostate cancer screening among older American men
Posted on November 18, 2015
Michael W. Drazer, Scott E. Eggener
University of Chicago Medical Center
Conflict of Interest: M.W.D.: No relationships to disclose

S.E.E.:
Consulting or Advisory Role: Myriad Genetics, Medivation, Janssen Pharmaceuticals, Genomic Health, OPKO Diagnostics, MDxHealth

Speaker’s Bureau: Myriad Genetics, Janseen Pharmaceuticals

Research Funding: Myriad Genetics (Inst)
To the Editor:

We read the recent letter from Guo and He with great interest and were particularly intrigued by their finding that patient-initiated screening increased in correlation with age.[1] Guo and He limited their analysis to men age 40-70 for unclear reasons, especially as a large proportion of men over the age of 70 are screened for prostate cancer. We recently reported that, in 2013, men age 75-79 were significantly more likely to be screened for prostate cancer than men in their fifties and one third of men over the age of 75 with less than nine years of estimated remaining life expectancy were screened. Prostate cancer screening among men age 75 and older declined from 44% in 2010 to 37% in 2013, yet the reason for this persistently high rate of screening among older men is unclear.[2] Therefore, it is important to understand why these men are continuing to be screened for prostate cancer despite a low likelihood of clinical benefit. Did Guo and He investigate patient-initiated screening among men age 70 and older in 2013? It would be intriguing to see what percentage of PSA tests ordered for men age 70 and older were ordered at the request of the patient and if patient expectations inordinately explain persistently high rates of screening among older men in light of our recent findings. One potential explanation for the high rates of screening among older men with limited remaining life expectancies may be testing “momentum” and patient expectations. We previously investigated the role of shared decision-making in the 2010 National Health Interview Survey and found similarly low rates of patient-initiated screening. It would be interesting to see how these findings have changed in response to the 2012 United States Preventive Services Task Force statement universally discouraging prostate cancer screening using the prostate-specific antigen assay.[3,4]

Michael W. Drazer, M.D.
Hematology/Oncology Fellow
University of Chicago Medical Center
Chicago, Illinois
Michael.Drazer@uchospitals.edu

Scott E. Eggener, M.D.
Associate Professor of Surgery; Co-Director, Prostate Cancer Program
The University of Chicago Medical Center
Chicago, Illinois
seggener@surgery.bsd.uchicago.edu


References

1. Guo F, He D: The Roles of Providers and Patients in the Overuse of Prostate-Specific Antigen Screening in the United States. Ann Intern Med 163:650-1, 2015
2. Drazer MW, Huo D, Eggener SE: National Prostate Cancer Screening Rates After the 2012 US Preventive Services Task Force Recommendation Discouraging Prostate-Specific Antigen-Based Screening. J Clin Oncol 33:2416-23, 2015
3. Drazer MW, Prasad SM, Huo D, et al: National trends in prostate cancer screening among older American men with limited 9-year life expectancies: evidence of an increased need for shared decision making. Cancer 120:1491-8, 2014
4. Moyer VA, Force USPST: Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 157:120-34, 2012

Author's Response
Posted on November 25, 2015
Fangjian Guo, MD, PhD
University of Texas Medical Branch
Conflict of Interest: None Declared
Drs. Drazer and Eggener raised an important issue concerning the overuse of Prostate-Specific Antigen (PSA) tests in older (>70 years of age) men. We restricted our analysis to men aged 40-70 years (1) for the reason that the 2008 United States Preventive Services Task Force (USPSTF) guideline has already recommended against routine PSA screening in older men (2). However, the high screening use of PSA test among men aged 75 and older (3) warrants further investigation in the role of shared decision-making in the overuse. Here, we assessed the proportion of doctor-recommended and patient-initiated screening PSA tests among older men (>70 years of age) in the United States using data form the 2013 National Health Interview Survey (NHIS).

After excluding 219 men with prostate cancer, 19 men with missing information on most recent PSA test, and 131 men who reported a PSA test in the past year for reasons other than “part of a routine exam”, we retained 1447 men (>70 years of age) from NHIS 2013 in the final analysis. Among those men, 33.5% aged 71-74 years, 37.0% aged 75-80 years, and 29.5% were older than 80 years. In the past year, 39.9% received screening PSA tests, and screening use decreased with age (47.9% , 41.8%, to 28.6% in those three age groups, respectively, p<0.001). Among 1447 men, 62.5% received doctors’ recommendations for PSA tests last year, and the proportions only decreased after age 80 (65.7%, 64.2%, and 56.7% in those three age groups, respectively). Among those who received PSA test in the past year, 96.0% received doctors’ recommendations for PSA tests, and the proportion of PSA tests attributable to Patients’ self-initiated increased with age (3.0%, 3.2%, and 7.4% in those three age groups, respectively). Among those who did not receive doctors’ recommendations for PSA tests last year, 4.3% received PSA test – patient initiated screening; the proportions were similar across those three age groups (4.2%, 3.8%, and 4.9%, respectively).

The high prevalence of screening PSA test after the release of the 2012 USPSTF guideline reflected lack of informed decision-making process as shown in our results. A similar situation is Papanicolaou (Pap) test overuse in older women (70+ years). Unlike older men, about 20% of Pap smears were self-initiated by those women (4). It is screening PSA test that increased prostate cancer incidence, and the decreased use of PSA test is accompanied with reduction in early-stage prostate cancer incidence (5).


References
1. Guo F, He D. The Roles of Providers and Patients in the Overuse of Prostate-Specific Antigen Screening in the United States. Ann Intern Med. 2015;163(8):650-1.
2. Moyer VA, Force USPST. Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157(2):120-34.
3. Drazer MW, Huo D, Eggener SE. National Prostate Cancer Screening Rates After the 2012 US Preventive Services Task Force Recommendation Discouraging Prostate-Specific Antigen-Based Screening. J Clin Oncol. 2015;33(22):2416-23.
4. Guo F, Hirth JM, Berenson AB. Cervical cancer screening among women ≥70 years of age in the United States - a referral problem or patient choice. Prev Med. 2015; 81:427-432.
5. Jemal A, Fedewa SA, Ma J, Siegel R, Lin CC, Brawley O, et al. Prostate Cancer Incidence and PSA Testing Patterns in Relation to USPSTF Screening Recommendations. JAMA. 2015;314(19):2054-61.


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