Low-Value Prostate-Specific Antigen Screening in Older Males

Kalavacherla, Sandhya; Riviere, Paul; Javier‐Desloges, Juan; Banegas, Matthew P.; McKay, Rana R.; Murphy, James D.; Rose, Brent S.

doi:10.1001/jamanetworkopen.2023.7504

Cited by 9 publications

(7 citation statements)

References 21 publications

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“…It is unclear whether the absence of specific guidance on screening transgender women contributed to this disparity. However, increased PSA screening among older patients (both cisgender men and transgender women) appears to be part of a larger trend recently characterized in other studies of the same BRFSS data …”

Section: Discussionmentioning

confidence: 64%

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Prostate Cancer Screening Uptake in Transgender Women

Kalavacherla,

Riviere,

Kalavacherla

et al. 2024

JAMA Netw Open

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ImportanceThere is no consensus in prostate-specific antigen (PSA) screening guidelines regarding transgender women despite their known prostate cancer risk.ObjectiveTo identify factors associated with recent (within the last 2 years) PSA screening in transgender women compared with cisgender men.Design, Setting, and ParticipantsThis case-control study used data from the 2018 and 2020 Behavioral Risk Factor Surveillance System (BRFSS) surveys to characterize rates of PSA screening for prostate cancer within the past 2 years and multivariable logistic regressions to characterize factors associated with recent screening among transgender women. The BRFSS program of the Centers for Disease Control and Prevention annually surveys over 400 000 US adults on behavioral risk factors, chronic illnesses, and use of preventive services. Respondents to the BRFSS who were cisgender men or transgender women 40 years or older and who had complete PSA testing responses and no prostate cancer history were included; 313 transgender women and 138 937 cisgender men met inclusion criteria. Matching was performed by age, race and ethnicity, educational level, employment, annual income, survey year, and cost barriers to care. Data were collected on November 2, 2022, and analyzed from November 2, 2022, to December 3, 2023.Main Outcomes and MeasuresRates of and factors associated with recent PSA screening in transgender women.ResultsAmong the 1275 participants included in the matched cohort (255 transgender women and 1020 cisgender men; 570 [44.7%] aged 55-69 years), recent PSA screening rates among transgender women and cisgender men aged 55 to 69 were 22.2% (n = 26) and 36.3% (n = 165), respectively; among those 70 years and older, these rates were 41.8% (n = 26) and 40.2% (n = 98), respectively. In the matched cohort, transgender women had lower univariable odds of recent screening than cisgender men (odds ratio [OR], 0.65 [95% CI, 0.46-0.92]; P = .02). In a hierarchical regression analysis adding time since the last primary care visit, effect size and significance were unchanged (OR, 0.61 [95% CI, 0.42-0.87]; P = .007). After adding whether a clinician recommended a PSA test, there was no statistically significant difference in odds of screening between transgender women and cisgender men (OR, 0.83 [95% CI, 0.45-1.27]; P = .21). The results were further attenuated when clinician-led discussions of PSA screening advantages and disadvantages were added (OR, 0.87 [95% CI, 0.47-1.31]; P = .32). In a multivariable logistic regression among transgender women, having a recommendation for PSA testing was the factor with the strongest association with recent screening (OR, 12.40 [95% CI, 4.47-37.80]; P &lt; .001).Conclusions and RelevanceIn this case-control study of one of the largest cohorts of transgender women studied regarding PSA screening, the findings suggest that access to care or sociodemographic factors were not principal drivers of the screening differences between transgender women and cisgender men; rather, these data underscore the clinician’s role in influencing PSA screening among transgender women.

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Section: Discussionmentioning

confidence: 64%

“…However, increased PSA screening among older patients (both cisgender men and transgender women) appears to be part of a larger trend recently characterized in other studies of the same BRFSS data. 25 , 26 …”

Section: Discussionmentioning

confidence: 99%

Prostate Cancer Screening Uptake in Transgender Women

Kalavacherla,

Riviere,

Kalavacherla

et al. 2024

JAMA Netw Open

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“…Though less common than among males ages 55–69 (21.6%), we observed that 13.1% of males ages 75 or older received a PSA test. There is little evidence of a mortality benefit of prostate cancer screening in this age group, and thus these males may be facing a higher risk of overdiagnosis and overtreatment without any potential mortality benefit [ 11 , 23 – 25 ].…”

Section: Discussionmentioning

confidence: 99%

Prostate-specific antigen testing rates in high-risk populations: results from the All of Us Research Program

Morley,

Iyer,

Tamimi

et al. 2023

Cancer Causes Control

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Background Early detection of prostate cancer using prostate-specific antigen (PSA) remains controversial and disparities in the receipt of prostate cancer screening persist in the US. We sought to examine disparities in PSA testing rates among groups with higher prostate cancer risk and differential access to healthcare. Methods We identified a cohort of 37,706 males within the All of Us Research Program without a history of prostate cancer between the ages of 40 and 85 at time of enrollment (2017–2021). Incidence rate ratios (IRR) for the number of PSA tests received during follow-up through December 2021 were estimated using age- and multivariable-adjusted negative binomial regression models. PSA testing frequencies in the cohort were compared with population-based estimates from the 2020 Behavioral Risk Factor Surveillance System (BRFSS). Results A total of 6,486 males (17.2%) received at least one PSA test over the course of follow-up. In multivariable-adjusted models, non-Hispanic Black males received PSA tests at a 17% lower rate (IRR = 0.83, 95% CI 0.76, 0.90) than non-Hispanic White males. Higher educational attainment, higher annual income, having self-/employer-purchased insurance, having a spouse or domestic partner, and having a family history of prostate cancer were all associated with higher rates of PSA testing. The proportion of males ages 55 to 69 who received a PSA test within two years was lower in All of Us (12.4%, 95% CI 11.8–13.0%) relative to population-based estimates from the BRFSS (35.2%, 95% CI 34.2–36.3%). Conclusion Absolute PSA testing rates in All of Us were lower than population-based estimates, but associations with PSA testing in the cohort mirrored previously reported disparities in prostate cancer screening. These findings highlight the importance of addressing barriers to care in order to reduce disparities in cancer screening.

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“… 9 There remains substantial controversy regarding prostate-specific antigen (PSA) screening for PCa, particularly its potential to result in overdiagnosis of low-risk disease. 10 Despite these concerns, PSA screening remains a commonly used tool, and both American Urological Association and American Cancer Society guidelines continue to include PSA screening for PCa diagnosis. 11 , 12 , 13…”

Section: Introductionmentioning

confidence: 99%

Cost-Effectiveness of Annual Prostate MRI and Potential MRI-Guided Biopsy After Prostate-Specific Antigen Test Results

Yun,

Kim,

Gandhe

et al. 2023

JAMA Netw Open

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ImportanceMagnetic resonance imaging (MRI) and potential MRI-guided biopsy enable enhanced identification of clinically significant prostate cancer. Despite proven efficacy, MRI and potential MRI-guided biopsy remain costly, and there is limited evidence regarding the cost-effectiveness of this approach in general and for different prostate-specific antigen (PSA) strata.ObjectiveTo examine the cost-effectiveness of integrating annual MRI and potential MRI-guided biopsy as part of clinical decision-making for men after being screened for prostate cancer compared with standard biopsy.Design, Setting, and ParticipantsUsing a decision analytic Markov cohort model, an economic evaluation was conducted projecting outcomes over 10 years for a hypothetical cohort of 65-year-old men in the US with 4 different PSA strata (&lt;2.5 ng/mL, 2.5-4.0 ng/mL, 4.1-10.0 ng/mL, &gt;10 ng/mL) identified by screening through Monte Carlo microsimulation with 10 000 trials. Model inputs for probabilities, costs in 2020 US dollars, and quality-adjusted life-years (QALYs) were from the literature and expert consultation. The model was specifically designed to reflect the US health care system, adopting a federal payer perspective (ie, Medicare).ExposuresMagnetic resonance imaging with potential MRI-guided biopsy and standard biopsy.Main Outcomes and MeasuresIncremental cost-effectiveness ratios (ICERs) using a willingness-to-pay threshold of $100 000 per QALY was estimated. One-way and probabilistic sensitivity analyses were performed.ResultsFor the 3 PSA strata of 2.5 ng/mL or greater, the MRI and potential MRI-guided biopsy strategy was cost-effective compared with standard biopsy (PSA 2.5-4.0 ng/mL: base-case ICER, $21 131/QALY; PSA 4.1-10.0 ng/mL: base-case ICER, $12 336/QALY; PSA &gt;10.0 ng/mL: base-case ICER, $6000/QALY). Results varied depending on the diagnostic accuracy of MRI and potential MRI-guided biopsy. Results of probabilistic sensitivity analyses showed that the MRI and potential MRI-guided biopsy strategy was cost-effective at the willingness-to-pay threshold of $100 000 per QALY in a range between 76% and 81% of simulations for each of the 3 PSA strata of 2.5 ng/mL or more.Conclusions and RelevanceThis economic evaluation of a hypothetical cohort suggests that an annual MRI and potential MRI-guided biopsy was a cost-effective option from a US federal payer perspective compared with standard biopsy for newly eligible male Medicare beneficiaries with a serum PSA level of 2.5 ng/mL or more.

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Low-Value Prostate-Specific Antigen Screening in Older Males

Cited by 9 publications

References 21 publications

Prostate Cancer Screening Uptake in Transgender Women

Prostate Cancer Screening Uptake in Transgender Women

Prostate-specific antigen testing rates in high-risk populations: results from the All of Us Research Program

Cost-Effectiveness of Annual Prostate MRI and Potential MRI-Guided Biopsy After Prostate-Specific Antigen Test Results

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