In 2012, an official federal panel designated routine PSA testing a Grade D: don't do it. Since then, doctors across the board have cut back on it. Not urologists, however. Their use of PSAs has not budged. Why? Simply, with more PSAs, abnormal results increase, and more urological procedures are done.
A new study in the current JAMA Internal Medicine assessed the overall and specialty-specific response of our nation's doctors to the 2012 federal panel advisory against doing routine prostate-specific antigen testing.
In the study, coming in the form of a research letter, entitled "Differences in Prostate-Specific Antigen Testing Among Urologists and Primary Care Physicians Following the 2012 USPSTF Recommendations," the authors compared the use of prostate-specific antigen, or PSA, testing among men aged 50 to 74 years before and after the guidelines were issued.
The authors are a group of seven urologists based at Brigham and Women's Hospital in Boston, led by Dr. Michael E. Zavaski.
The federal panel is the United States Preventive Services Task Forces, otherwise known as the USPSTF.
After the panel's guidelines were issued, a decline in rates of PSA testing among men aged 50 to 74 years, and a decline in cases of incident prostate cancer, were observed. The authors sought to compare the use of PSA testing among urologists vs. primary care physicians (PCPs) before and after the latest USPSTF guidelines. They hypothesized that the adoption of these recommendations would vary according to physician specialty (men with known prostate-related conditions were excluded from the analysis). And right they were!
Using data from the CDC's National Ambulatory Care Survey in 2010, as compared with that of 2012, the authors dichotomized the responding physicians into PCPs internists and generalists and Urologists, and determined what percentage of each group persisted in ordering PSAs routinely on their patients. Lo and behold: among PCPs, PSA testing declined from 36.5 percent to 16.4 percent over the two-year interval, which was highly significant.
Among the Urologists, 38.7 percent initially ordered PSAs routinely; the figure declined only to 34.5 percent, which was an insignificant change.
The authors posit several rationales for this divergence:
- A -- differences in physician perception of the utility of PSA
- B -- conflicting guidelines (the American Urological Association recommends "joint decision making")
- C -- differences in patient demographics and/or expectations
The highly-polite professionals (urologists, in fact) authoring this report declined to address the cash cow in the room. Simply put, the more PSAs, the more abnormal PSAs, the more (urological) procedures to be done.
Look, the alternative is that urologists simply do not share other doctors' faith in evidence-based medicine, as exemplified by the objective scientists empaneled at the USPSTF. Or, they are too dense to absorb this simple advisory, pointing out that routine PSA tests do more harm than good.
When I was in medical school and residency back then, we did look down upon those studying urology as not being quite up to par with us geniuses in medicine (although we secretly envied their likely income levels to come). But seriously, they are surely wise enough to know that PSAs done without specific indication lead to biopsies and debilitating prostatectomies for (all too often) no benefit except to their incomes.