Predictors of Low-Value PSA Screening in Elderly Men

Abstract

<h3>Purpose/Objective(s)</h3> The US Preventive Services Task Force (USPSTF) advises against prostate-specific antigen (PSA) testing for prostate cancer in men over 70 and identifies men aged 55 - 69 as the target screening group. The PSA test for prostate cancer is limited by its high false-positive rate and often leads to overdiagnosis of prostate cancer. Together, these can expose patients to anxiety, invasive biopsies, and possible over-treatment. We evaluate the predictors of recent PSA testing in men over 70 using Behavioral Risk Factor Surveillance System (BRFSS) survey data. <h3>Materials/Methods</h3> BRFSS 2020 data from PSA-related questions were analyzed, including time since last PSA test, PSA test reason, and whether a provider discussed the advantages and disadvantages of PSA screening with respondents. Men over 70 who answered PSA-related questions met our study criteria. We defined "recent testing" as having had a PSA test within the past two years. We used weighted multivariable logistic regressions with two-sided significance tests to measure effects of age, insurance status, having a primary care physician (PCP), and having discussion of PSA test risks and benefits with a provider on recent testing. Recent testing rates and percentages of men tested via routine screening vs. prostate-specific evaluations were calculated. <h3>Results</h3> Our cohort included 33,556 men. Recent PSA testing was high in men over 70. Men aged 70-75, 75-80, 80+ had testing rates of 56.3%, 53.4%, and 40.8% respectively. In a multivariable regression model, positive predictors of recent testing in men over 70 included being insured (OR = 1.202, 95% CI 1.195 - 1.21, p < 0.001), having a PCP (OR = 1.459, 95% CI 1.454 - 1.465, p < 0.001), and discussing the advantages of PSA testing with a PCP (OR = 3.507, 95% CI 3.5 - 3.515, p < 0.001). Discussing the disadvantages of PSA testing with a PCP had only a small, negative effect on recent testing in men over 70 (OR = 0.996, 95% CI 0.995 - 0.998, p < 0.001). Among men over 70 who had recent PSA tests, 73.3% reported routine testing as the main reason for their tests. We repeated our analysis with the unweighted survey data and found no significant changes in results. <h3>Conclusion</h3> Despite USPSTF guidelines, men over 70 continue to be screened with PSA at a high rate. Routine testing accounted for the majority of recent PSA tests in men over 70. Having a discussion of the benefits of PSA tests with a provider had the largest effect on recent testing in men over 70, which underscores the role of the provider in positively influencing PSA testing rates. Other related predictors of PSA testing in men over 70 included being insured and having a PCP. These findings suggest changes can be made at the provider-level to increase adherence to guidelines on age-based PSA testing.