Unintended consequences of decreased PSA-based prostate cancer screening

Abstract

Background

In May 2012, the US Preventive Services Task Force issued a grade D recommendation against PSA-based prostate cancer screening. Epidemiologists have concerns that an unintended consequence is a problematic increase in high-risk disease and subsequent prostate cancer-specific mortality.

Materials and methods

To assess the effect of decreased PSA screening on the presentation of high-risk prostate cancer post-radical prostatectomy (RP). Nine high-volume referral centers throughout the United States (n = 19,602) from October 2008 through September 2016 were assessed and absolute number of men presenting with GS ≥ 8, seminal vesicle and lymph node invasion were compared with propensity score matching.

Results

Compared to the 4-year average pre-(Oct. 2008–Sept. 2012) versus post-(Oct. 2012–Sept. 2016) recommendation, a 22.6% reduction in surgical volume and increases in median PSA (5.1–5.8 ng/mL) and mean age (60.8–62.0 years) were observed. The proportion of low-grade GS 3 + 3 cancers decreased significantly (30.2–17.1%) while high-grade GS 8 + cancers increased (8.4–13.5%). There was a 24% increase in absolute numbers of GS 8+ cancers. One-year biochemical recurrence rose from 6.2 to 17.5%. To discern whether increases in high-risk disease were due to referral patterns, propensity score matching was performed. Forest plots of odds ratios adjusted for age and PSA showed significant increases in pathologic stage, grade, and lymph node involvement.

Conclusions

All centers experienced consistent decreases of low-grade disease and absolute increases in intermediate and high-risk cancer. For any given age and PSA, propensity matching demonstrates more aggressive disease in the post-recommendation era.

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Change history

  • 22 July 2019

    In the original publication, part of funding information was missed.

Abbreviations

PSA:

Prostate-specific antigen

USPSTF:

United States Preventive Services Task Force

GS:

Gleason score

RP:

Radical prostatectomy

SVI:

Seminal vesicle invasion

LNI:

Lymph node involvement

BCR:

Biochemical recurrence

PCSM:

Prostate cancer-specific mortality

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Acknowledgements

Special thanks to the Urology research coordinators, fellows, and students who have contributed to data collection and collation: Erica Huang, Anthony Warner, Omesh Ranasinghe, Bonita Powell, Kellie McWilliams, Mary Achim, Pascal Mouracade (MD), Tadzia Harvey, Brian Shinder (MD). In support of Dr. Edward and Arthur Lui (MD) and in memory of their parents Mr. and Mrs. L.H.M Lui.

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Correspondence to Thomas Ahlering.

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Ahlering, T., Huynh, L.M., Kaler, K.S. et al. Unintended consequences of decreased PSA-based prostate cancer screening. World J Urol 37, 489–496 (2019). https://doi.org/10.1007/s00345-018-2407-3

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Keywords

  • Prostate cancer
  • Screening
  • USPSTF recommendation
  • High risk