Date Published: June 13, 2019
Publisher: Public Library of Science
Author(s): Stefan Zechmann, Stefania Di Gangi, Vladimir Kaplan, Rahel Meier, Thomas Rosemann, Fabio Valeri, Oliver Senn, Bart Ferket.
Following years of controversy regarding screening for prostate cancer using prostate-specific antigen, evidence evolves towards a more restrained and preference-based use. This study reports the impact of landmark trials and updated recommendations on the incidence rate of prostate cancer screening by Swiss general practitioners.
We performed a retrospective analysis of primary care data, separated in 3 time periods based on dates of publications of important prostate-specific antigen screening recommendations. 1: 2010-mid 2012 including 2 updates; 2: mid 2012-mid 2014 including a Smarter Medicine recommendation; 3: mid-2014—mid-2017 maintenance period. Period 2 including the Smarter Medicine recommendation was defined as reference period. We further assessed the influence of patient’s age and the number of prostate-specific-antigen (PSA) tests, by the patient and within each time period, on the mean PSA concentration. Uni- and multivariable analyses were used as needed.
36,800 men aged 55 to 75 years were included. 14.6% had ≥ 2 chronic conditions, 11.7% had ≥ 1 prostate-specific antigen test, (mean 2.60 ng/ml [SD 12.3]). 113,921 patient-years were covered. Data derived from 221 general practitioners, 33.5% of GP were women, mean age was 49.4 years (SD 10.0), 67.9% used prostate-specific antigen testing. Adjusted incidence rate-ratio (95%-CI) dropped significantly over time periods: Reference Period 2: incidence rate-ratio 1.00; Period 1: incidence rate-ratio 1.74 (1.59–1.90); Period 3: incidence rate-ratio 0.61 (0.56–0.67). A higher number of chronic conditions and a patient age between 60–69 years were significantly associated with higher screening rate. Increasing numbers of PSA testing per patient, as well as increasing age, were independently and significantly associated with an increase in the PSA value.
Swiss general practitioners adapted screening behavior as early as evidence of a limited health benefit evolved, while using a risk-adapted approach whenever performing multiple testing. Updated recommendations might have helped to maintain this decrease. Further recommendations and campaigns should aimed at older patients with multimorbidity, to sustain a further decline in prostate-specific antigen screening practices.
Screening for prostate cancer (PC) using prostate-specific antigen (PSA) has been controversial for many years. As evidence evolved, recommendations changed towards a more restrained and preference-based use.
For this retrospective longitudinal study we calculated the incidence rates of PSA testing in Swiss primary care male patients from 2010 to 2017.
Swiss GPs reduced PSA screening once evidence to be more cautious evolved. The biggest reduction in PSA screening was observed within 3 years after the publications of the landmark trials (PLCO and ERSPC) and before the updated screening recommendations of various authorities (e.g. SMB, USPSTF, and SSM). Patients`older age and a higher number of chronic conditions were independently associated with higher screening rates.
Swiss GPs adapted their PC screening behavior as early as evidence of a limited health benefit evolved while using a risk-adapted approach whenever performing multiple testing. Thus, PSA testing rate significantly decreased from 2010 to 2012, while subsequent campaigns and recommendations had only a minor impact on further testing incidence rates. Older age and a higher number of chronic conditions of the patients were associated with higher screening rates. Further recommendations and campaigns should be aimed at these subgroups, to maintain and further decline PC screening practices to individual patients giving them the opportunity to discuss the potential benefits and harms of screening .