Rejecting the recommendations, urologists and older docs persist in ordering prostate screening

The USPSTF’s reiterated recommendations against prostate-cancer screening for men with limited life expectancy have resonated with geriatricians and younger primary care physicians but failed to sway substantial numbers of urologists and older practitioners, as shown by a large study of veterans published April 4 in JAMA Internal Medicine.

The study report, lead-authored by Victoria Tang, MD, of University of California, San Francisco and the VA center in that city, shows that in 2011—three years after the recommendation and the very year it was expanded to include men of all ages—more than half of 466,017 men aged 65 and up received prostate-specific antigen (PSA) screening.

Among the screened were 39 percent of 203,717 men with limited life expectancy.

Additionally, men whose PSA-ordering clinician was a physician trainee had substantially lower PSA screening rates than those with an older attending physician, nurse practitioner or physician assistant.

Tang et al. arrived at their findings by performing a cross-sectional study of 826,286 veterans aged 65 years and up who had lab tests performed within the VA system in 2011.

Defining limited life expectancy as age of at least 85 years with Charlson comorbidity score of 1 or greater or age of at least 65 years with Charlson comorbidity score of 4 or greater, they uncovered the persistence of the association between higher PSA screening rates in patients with limited life expectancy and ordering clinicians who were older and no longer in training.

The gaps in PSA screening rates ranged from:

• Just 22 percent for men with a geriatrician as their clinician to as high as 82 percent for men with a urologist;
• 29 percent for men with a clinician 35 years or younger to 41 percent for those with a clinician 56 years or older;  
• 38 percent for men with a female clinician older than 55 years vs. 43 percent for men with a male clinician older than 55 years; and
• 27 percent for men with a physician trainee to 42 percent for men with an attending physician.

Noting that potential PSA screening harms include physical and psychological adverse events from follow-up procedures and treatments, the authors call for educational interventions discouraging the screening in men with limited life expectancy.

Tang and colleagues further suggest removing best-practice alerts that encourage PSA screening regardless of life expectancy, and they stress that interventions “designed and targeted to the highest users of PSA screening—older male, nontrainee clinicians—will likely have the greatest impact in reducing PSA screening in older men with limited life expectancy.”