Clinical Laboratory Strategies: August 9, 2007

Going Outside the Guidelines
Recent Data Identify Some Reasons Why Clinicians Stray from PSA Testing Recommendations
By Julie McDowell

Current guidelines do not recommend routine prostate-specific antigen (PSA) screening for men younger than 40, older than 75, or those expected to live less than 10 years. However, a recent study of patients in the Boston area Veterans’ Administration system found that many clinicians order PSA tests for patients in populations outside the upper range of these guidelines. This issue of Strategies examines some of this research into the rationale behind inappropriate prostate cancer screenings.

Much of the debate among laboratorians and clinicians surrounding PSA screening is centered on the test’s limitations in distinguishing between benign prostate conditions and cancer. In contrast, there is little controversy among clinical practice guidelines about who should not be screened. Because there is no solid evidence linking screening to benefits among young and older men, there are no current clinical guidelines recommending PSA testing in asymptomatic men younger than 40 and older then 75.

But a recent study in the Archives of Internal Medicine indicates that testing of these populations might be more common than initially believed, particularly if the ordering clinician is an older male [2007;167(13):1367–1372]. An analysis of data on over 232,000 PSA tests ordered from 1997 to 2004 on patients treated in Veterans Health Affairs facilities in New England found over 16% of screenings would be considered inappropriate. Of these screenings, approximately 15% were performed in patients older than 75, and less than 1% were performed in patients younger than 40.

“The results confirmed that PSA screening was performed inappropriately in a significant proportion of cases,” said B. Price Kerfoot, MD, of the Veterans Affairs Boston Healthcare System and Harvard Medical School in Boston. The degree of inappropriate screening was associated with several provider-level characteristics, he explained. “We performed our analysis based on previous data showing gender and age-specific differences in cancer screening and found that the percentage of inappropriate screening increased significantly with the age of the male healthcare providers. The cause for this is really not known, but we hypothesized that as male healthcare providers age, they increasingly empathize with their older male patients over prostate cancer concerns, and that led us to coin the term ‘prostatempathy.’” Kerfoot and his colleagues’ analysis also found that of the healthcare providers who ordered inappropriate PSA tests, 79.4% were physicians, 53.4% were trainee physicians, and 8.2% were urologists.

In addition to the prostatempathy hypothesis, Kerfoot believes that one explanation for the inappropriate screening rates has to do with unfamiliarity with the guidelines. Therefore, he believes there is promise in online education programs for providers, as well as other electronic tools. “One option is to actually change the method by which PSA ordering is done, in order to put up road blocks in the ordering process if tests are ordered for inappropriate age groups,” he explained. However, he realizes that physicians typically don’t like these systems and view them as a nuisance. “But I would like to further explore where we can use medical education and technology to see if we can intervene prior to the process of test ordering,” he explained.

Requesting the Test

The argument against screening men over 75 and a less than 10 year life expectancy is sound to most clinical laboratorians who cite data that these men will probably not die from prostate cancer, but from some other disease, and shouldn’t undergo surgery or other invasive therapy. However, many of these men will request these tests, explained Robert Getzenberg, PhD, Professor of Urology and Director of Research at Johns Hopkins University’s James Buchanan Brady Urological Institute. “Many clinicians will order the test if it’s requested by a patient who wants to know what’s going on with their prostate,” he said, adding that it’s not really in the patient’s best interest to tell them that they have prostate cancer if it’s not recommended they undergo a potentially curative treatment and the side effects.

However, PSA screening among younger men is a more complicated issue. “We’re seeing more young men with prostate cancer,” he said. It’s possible that certain individuals—such as those with a family history or urological symptoms of prostate cancer—should be screened, even if they are younger than 40. “I think there are a group of individuals where earlier PSA levels may actually be acceptable,” he explained. “At some point in the future we might actually encourage them to get tested.”

Whether the patient is young or old, it’s difficult for clinicians to turn people away from available diagnostic technologies, but it’s important for healthcare providers to be careful. “We’re not always going to want to carry through with the treatment that goes along with the prostate cancer diagnosis,” Getzenberg explained. “In fact, we know that most of these people 75 and older will have some evidence of prostate cancer. As a medical community, I think we need to say that this is a population we should leave alone. But the younger group is an evolving story—I think there is going to be evidence coming out demonstrating that there might be reason to test certain people sooner.”

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