Academy of Diagnostics & Laboratory Medicine - Scientific Short

Implications of Recent Data Analysis Regarding Insurance Claims for PSA Testing: Time for Practice Intervention?

Shahram Shahangian, PhD and Lin Fan, PhD

Prostate-specific antigen (PSA) testing to screen for prostate cancer began in the 1990’s despite lack of evidence for its clinical utility. This laboratory test is currently the most commonly used cancer screening test in men. In May 2012, U.S. Preventive Services Task Force (USPSTF),1 along with American College of Preventive Medicine and Academy of Family Physicians, recommended against PSA screening of all men regardless of age.2 The USPSTF issued a draft statement in April 2017 recommending that clinicians inform men ages 55 to 69 years about the potential benefits and harms of screening,3 but a final recommendation update has not yet been issued. For men older than 69, all healthcare organizations have recommended against PSA screening.4,5 Recommendations are either to not screen for prostate cancer using the PSA test or offer screening men beginning at age 50–55 until age 69 who have at least 10 years of life expectancy, and to do so only after a process of informed and shared decision making. This study was undertaken to provide information to inform interventions to promote evidence-based screening recommendations. To do so, we evaluated the extent of PSA screening in different age groups from 2009 through 2015 using claims data from a large sample of privately insured men and all Medicare enrollees age 30 or older.

Claims data related to 9.9–16.6 million men age 30–64 years and 17.7–21.8 million men age 65 or older. We further evaluated screening rates and trends in the 9 US census divisions to determine the extent of geographic variability in PSA screening practices. We used a 2-sided Poisson regression model to evaluate trends in annual screening rates from 2009 through 2015. To consider PSA testing for screening only, all claims associated with any prostate or urinary conditions were deleted since PSA testing in such cases may have been for purposes other than screening.

Annual PSA screening rates in the studied populations were: 2%, age 30–39; 13%–14%, age 40–49; 30%–32%, age 50–64; 9%–13%, age 65–69; 11%–15%, age 70–74; and 6%–11%, age 75 or older. Annual testing trend was significantly downward only for men age 70–74. The greatest relative decrease in PSA screening rate in different age groups was 5%–16% from 2011 to 2012, while the greatest increase was 3%–30% from 2014 to 2015. The highest screening rate was in the East South Central division, and this was 1.4–2.5 times the lowest screening rate which we saw in the Pacific division.

This study shows that professional recommendations against screening had only a modest impact on using PSA test to screen for prostate cancer. Continuing use of PSA screening in men younger than 50 and older than 69 points to opportunities to dissuade use of PSA screening in these men. Ability to avoid treating 80% of men with low-grade disease, who will never die of prostate cancer, would save an excess of $1.3 billion nationally and is expected to increase many years of quality-adjusted life years.6 Approximately 5 in 1000 men die within 1 month of radical prostatectomy and 200–300 will experience impotence, urinary incontinence, or both. There is a need to better understand why PSA screening is performed in men younger than 50–55 and older than 69.


References


  1. Moyer VA; U.S. Preventive Services Task Force. Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157:120–134.
  2. Pinsky PF, Prorok PC, Kramer BS. Prostate cancer screening – a perspective on the current state of the evidence. N Engl J Med. 2017; 376:1285–1289.
  3. U.S. Preventive Services Task Force.Draft Recommendation Statement – Prostate Cancer: Screening. Issued on April 11, 2017; public comment closed on May 8, 2017. https://www.uspreventiveservicestaskforce.org/page/document/draft-recommendation-statement/prostate-cancer-screening1. Accessed February 2, 2018.
  4. Smith RA, Andrews KS, Brooks D, et al. Cancer screening in the United States, 2017: a review of current American Cancer Society guidelines and current issues in cancer screening. CA Cancer J Clin. 2017;67:101–121.
  5. Carter HB, Albertsen PC, Barry MJ, et al. Early detection of prostate cancer: AUA guideline. J Urol. 2013;190:419–426.
  6. Aizer AA, Gu X, Chen M-H, et al. Cost implications and complications of overtreatment of low-risk prostate cancer in the United States. J Natl Compr Canc Netw. 2015;13:61–68.

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Fellows of the Academy use the designation of FADLM. This designation is equivalent to FACB and FAACC, the previous designations used by fellows of the National Academy of Clinical Biochemistry and AACC Academy. Those groups were rebranded as Academy of Diagnostics & Laboratory Medicine in 2023.