A continuous fall of PSA use for prostate cancer screening among Brazilian doctors since 2001. Good or bad notice?

Abstract

Purpose:To evaluate the trend of use of Prostate Specific Antigen (PSA) for screening of prostate cancer (PC) among Brazilian doctors, from the beginning of its regular availability in clinical laboratories.Material and Methods:A serial cross-sectional study was performed using data obtained from a large database between 1997 and 2016. The general PSA screening trend during this period, adjusted for the total number of exams performed in men, was analyzed. Time-series analysis was performed through observation of the general regression curve using the generalized least squares method, and the impact of the recommendations was assessed with autoregressive integrated moving average (ARIMA) models.Results:During the period studied 2,521,383 PSA determinations were done. The age of the participants ranged from 21 to 111 years, with an average of 56.7 ± 22.7 years. The relative number of PSA tests/100.000 exams in males showed a constant reduction since 2001, and this trend was more evident in the group aged 55-69 years. Although statistically significant, the impact of reduced PSA screening after the 2012 USPSTF publication was clinically irrelevant.Conclusions:Our results indicated a continuous reduction in the use of PSA screening over time, regardless of the publication of recommendations or clinical guidelines. The fact that this trend was more pronounced among those with a greater benefit potential (55-69 years), relative to groups with a greater damage potential due to overdiagnosis and overtreatment (aged >74 years and <40 years), is a matter of concern. Follow-up studies of these trends are advisable.

Overdiagnosis no contexto do câncer

“…Esse fato se dá principalmente pela grande quantidade de cânceres indolentes que são diagnosticados de forma indevida (Charvin et al, 2020;Modesto et al, 2017;Pinsky et al, 2017;Soares et al, 2019). Por conseguinte, os estudos de autópsias mostram que mais de 50% dos homens acima de 80 anos possuem células malignas na próstata mesmo não tendo demonstrado sintomas, estima-se que grande quantidade de tumores malignos localizados não trariam risco a vida do paciente, pois teriam evolução lenta ou progressão muito lenta, sendo incapaz de gerar sintomas (Araújo et al, 2019;Charvin et al, 2020).…”

“…Devido a essa imprecisão diagnóstica existente há uma tendência em se tratar de agressiva pacientes considerados de baixo risco pois há a preocupação que o câncer deste possa evoluir para um mais agressivo. Dessa forma temse documentado que 43% das prostatectomias são realizadas em pacientes com câncer indolente na análise histopatológica e 60% dos que são submetidos a radioterapia mais prostatectomias possuíam a doença no grau tipo 1, ou seja, pouco agressiva (Araújo et al, 2019;Modesto et al, 2017;Pinsky et al, 2017;Soares et al, 2019).…”

“…Devido a dimensão continental do país, a triagem com PSA ainda é um método barato, disponível e de fácil acesso por parte dos usuários do sistema único de saúde. Outros métodos de triagem e diagnóstico como Ressonância Nuclear Magnética ou Ultrassonografia de 12 núcleos ainda são métodos caros e pouco acessíveis dificultando seu uso em grande escala, caso essa combinação fosse possível existiria a possibilidade da diminuição da chance de Overdiagnosis pois se trata de uma estratégia mais sensível (Araújo et al, 2019;Kovac et al, 2020;Martin et al, 2018). Charvin et al, 2020 analisaram a percepção dos homens em relação ao rastreio do câncer de próstata.…”

Trends in prostate cancer incidence and mortality to monitor control policies in a northeastern Brazilian state

“…Conversely, Araujo et al . observed a reduction of PSA testing rates starting in 2009 in private laboratories but not among men aged >74 [ 27 ]. Earlier observational studies demonstrated that the increased number of biopsies and the diagnosis of indolent tumors did not yield benefits, and the impact on mortality was questionable, leading to unnecessary treatment risks, such as impotence and urinary complications [ 28 – 31 ].…”

Prostate cancer awareness in the city of São Paulo

“…(11) In Brazil, compliance to the SBU guideline is lower compared to that of the American Urological Association (AUA). (12) The different compliance trends observed in many countries have a multifactorial cause. One of them is patient health literacy, which should be affected by educational campaigns.…”