Prostate cancer screening in Primary Health Care: the current state of affairs

Attitudes Toward and Use of Prostate-Specific Antigen Testing Among Urologists and General Practitioners in Germany: A Survey

Background

In 2020, around 1.4 million new prostate cancer (PCa) cases were recorded worldwide. Early detection of PCa by prostate-specific antigen (PSA) screening remains debated, leading to different specialist-specific recommendations in PCa guidelines. This study aimed to assess attitudes toward and use of PSA testing among urologists in Germany and general practitioners (GPs) in Lower Saxony (Germany).

Methods

A nationwide questionnaire was sent to urologists via the mailing lists of the Professional Association of German Urologists and the German Urological Society. A version of the questionnaire for GPs was sent to email addresses via the Association of Statutory Health Insurance Physicians Lower Saxony. The online questionnaires covered use of PSA testing, information communication, handling of test results, and handling of/knowledge about national and international guidelines and recommendations on early detection of PCa. Statistical analysis was performed at a descriptive level.

Results

In total, 432 of 6,568 urologists (6.6%) and 96 of 1,579 GPs (6.1%) participated in this survey. Urologists and GPs differed in their attitudes and approaches toward PSA testing. Most urologists (86.8%, n=375) judged the test as “very meaningful” or “meaningful”, compared with 52.1% (n=50) of GPs. Almost two-thirds of the urologists (64.4%, n=278) viewed the PCa mortality reduction by PSA testing as proven, compared with one-fifth of GPs (20.8%, n=20). Almost 80% of male urologists (79.9%, n=291) indicated that they would undergo a PSA test in the future (again), compared with 55.1% of male GPs (n=38). In addition, 56.3% (n=243) of urologists stated that “considerably more than half” or “almost all” men aged 45 years or older received a PSA test, compared with 19.8% (n=19) of GPs.

Conclusions

Urologists are more convinced about the PSA test than GPs. PSA testing is therefore used more often in urological settings, although the preselected patient population must be considered. In accordance with specialist-specific recommendations, GPs show a more reserved approach toward PSA testing. Instead of focusing on different attitudes and recommendations on PSA testing, the exchange between specialist groups should be improved to achieve a consistent approach to PSA testing.

General practitioners' approaches to prostate-specific antigen testing in the north-east of the Netherlands

BACKGROUND

There is wide variation in clinical practice for the early detection of prostate cancer, not least because of the ongoing debate about the benefits of prostate-specific antigen (PSA) testing. In this study, we aimed to assess the approaches, attitudes, and knowledge of general practitioners (GPs) regarding PSA testing in primary care in the Netherlands, particularly regarding recommendations for prostate cancer.

METHODS

Questionnaire surveys were sent to 179 GPs in the north-east of the Netherlands, of which 65 (36%) were completed and returned. We also surveyed 23 GPs attending a postgraduate train-the-trainer day (100%). In addition to demographic data and practice characteristics, the 31-item questionnaire covered the attitudes, clinical practice, adherence to PSA screening recommendations, and knowledge concerning the recommendations for prostate cancer early detection. Statistical analysis was limited to the descriptive level.

RESULTS

Most GPs (95%; n = 82) stated that they had at least read the Dutch GP guideline, but just half (50%; n = 43) also stated that they knew the content. Almost half (46%; n = 39) stated they would offer detailed counseling before ordering a PSA test to an asymptomatic man requesting a test. Overall, prostate cancer screening was reported to be of minor importance compared to other types of cancer screening.

CONCLUSIONS

Clinical PSA testing in primary care in this region of the Netherlands seems generally to be consistent with the relevant guideline for Dutch GPs that is restrictive to PSA testing. The next step will be to further evaluate the effects of the several PSA testing strategies.

The effect of assessing genetic risk of prostate cancer on the use of PSA tests in primary care: A cluster randomized controlled trial

BACKGROUND

Assessing genetic lifetime risk for prostate cancer has been proposed as a means of risk stratification to identify those for whom prostate-specific antigen (PSA) testing is likely to be most valuable. This project aimed to test the effect of introducing a genetic test for lifetime risk of prostate cancer in general practice on future PSA testing.

METHODS AND FINDINGS

We performed a cluster randomized controlled trial with randomization at the level of general practices (73 in each of two arms) in the Central Region (Region Midtjylland) of Denmark. In intervention practices, men were offered a genetic test (based on genotyping of 33 risk-associated single nucleotide polymorphisms) in addition to the standard PSA test that informed them about lifetime genetic risk of prostate cancer and distinguished between "normal" and "high" risk. The primary outcome was the proportion of men having a repeated PSA test within 2 years. A multilevel logistic regression model was used to test the association. After applying the exclusion criteria, 3,558 men were recruited in intervention practices, with 1,235 (34.7%) receiving the genetic test, and 4,242 men were recruited in control practices. Men with high genetic risk had a higher propensity for repeated PSA testing within 2 years than men with normal genetic risk (odds ratio [OR] = 8.94, p < 0.01). The study was conducted in routine practice and had some selection bias, which is evidenced by the relatively large proportion of younger and higher income participants taking the genetic test.

CONCLUSIONS

Providing general practitioners (GPs) with access to a genetic test to assess lifetime risk of prostate cancer did not reduce the overall number of future PSA tests. However, among men who had a genetic test, knowledge of genetic risk significantly influenced future PSA testing.

TRIAL REGISTRATION

This study is registered with ClinicalTrials.gov, number NCT01739062.

Impact of United States Preventive Services Task Force recommendations on prostate biopsy characteristics and disease presentation at a tertiary-care medical center

BACKGROUND

To evaluate early consequences of 2012 United States Preventive Services Task Force (USPSTF) recommendations for decreased prostate-specific antigen (PSA) screening on prostate biopsy characteristics and prostate cancer presentation.

MATERIALS AND METHODS

A single tertiary-care institution, multisurgeon, prospectively maintained database was queried for patients undergoing prostate biopsy from October 2005 to September 2016. Patient demographics, biopsy characteristics, and extent of disease were reported. Patient cohorts before and after USPSTF recommendations were compared using two-sample t test, Chi-square test, and Wilcoxon rank sum test with significance at P < 0.05.

RESULTS

A total of 2,000 patients were analyzed, including 1,440 patients before and 560 patients after USPSTF recommendations. Following the recommendations, patients had higher prebiopsy PSA (5.90 vs. 6.70, P < 0.001). Overall, 817 (40.9%) patients had prostate cancer detected at biopsy with an increase from 37.0% before to 50.8% after (P < 0.001). Biopsies detected less low-risk Gleason ≤6 prostate cancer (47.4% vs. 41.1%) and more intermediate-risk Gleason 7 cancer (30.9% vs. 39.7%), with comparable findings of high-risk Gleason ≥8 cancer (21.7% vs. 19.2%), P = 0.042. In addition, greater percentage of core involvement (P < 0.001) was seen. At the time of diagnosis, extraprostatic extension identified by pelvic imaging increased from 12.6% to 18.9%, P = 0.039, with a trend toward lymph node positivity (1.1% vs. 2.2%, P = 0.078). Of those with metastatic disease, bony involvement occurred more often (1.7% vs. 3.2%, P = 0.041).

CONCLUSIONS

After 2012 USPSTF guidelines, patients presented with higher PSA with prostate cancer were detected more frequently. More adverse, pathologic prostate cancer features were found on biopsy with the extent of disease implicating locally advanced/metastatic disease. These findings should be considered when counseling patients about prostate cancer screening importance.

Factors associated with prostate specific antigen testing in Australians: Analysis of the New South Wales 45 and Up Study

Australia has one of the highest incidence rates of prostate cancer (PC) worldwide, due in part to widespread prostate specific antigen (PSA) testing. We aimed to identify factors associated with PSA testing in Australian men without a diagnosis of prostate cancer or prior prostate disease. Participants were men joining the 45 and Up Study in 2006–2009, aged ≥45 years at recruitment. Self-completed questionnaires were linked to cancer registrations, hospitalisations, health services data and deaths. Men with a history of PC, radical prostatectomy or a “monitoring” PSA test for prostate disease were excluded. We identified Medicare reimbursed PSA tests during 2012–2014. Multivariable logistic regression was used to estimate adjusted odds ratios (OR) for the association between having PSA tests and factors of interest. Of the 62,765 eligible men, 51.8% had at least one screening PSA test during 2012–2014. Factors strongly associated with having a PSA test included having 27+ general practitioner consultations (versus 3–9 consultations; OR = 2.00; 95%CI = 1.90–2.11), benign prostatic hyperplasia treatment (versus none; OR = 1.59(95%CI = 1.49–1.70), aged 60–69 years (versus 50–59 years; OR = 1.54; 95%CI = 1.48–1.60). These results emphasise the important role of primary care in decision making about PSA testing.

Quantification of large scale DNA organization for predicting prostate cancer recurrence

This study investigates whether Genomic Organization at Large Scales (which we propose to call GOALS) as quantified via nuclear phenotype characteristics and cell sociology features (describing cell organization within tissue) collected from prostate tissue microarrays (TMAs) can separate biochemical failure from biochemical nonevidence of disease (BNED) after radical prostatectomy (RP). Of the 78 prostate cancer tissue cores collected from patients treated with RP, 16 who developed biochemical relapse (failure group) and 16 who were BNED patients (nonfailure group) were included in the analyses (36 cores from 32 patients). A section from this TMA was stained stoichiometrically for DNA using the Feulgen-Thionin methodology, and scanned with a Pannoramic MIDI scanner. Approximately 110 nuclear phenotypic features, predominately quantifying large scale DNA organization (GOALS), were extracted from each segmented nuclei. In addition, the centers of these segmented nuclei defined a Voronoi tessellation and subsequent architectural analysis. Prostate TMA core classification as biochemical failure or BNED after RP using GOALS features was conducted (a) based on cell type and cell position within the epithelium (all cells, all epithelial cells, epithelial >2 cell layers away from basement membrane) from all cores, and (b) based on epithelial cells more than two cell layers from the basement membrane using a Classifier trained on Gleason 6, 8, 9 (16 cores) only and applied to a Test set consisting of the Gleason 7 cores (20 cores). Successful core classification as biochemical failure or BNED after RP by a linear classifier was 75% using all cells, 83% using all epithelial cells, and 86% using epithelial >2 layers. Overall success of predicted classification by the linear Classifier of (b) was 87.5% using the Training Set and 80% using the Test Set. Overall success of predicted progression using Gleason score alone was 75% for Gleason >7 as failures and 69% for Gleason >6 as failures. © 2017 International Society for Advancement of Cytometry.

What affects response rates in primary healthcare-based programmes? An analysis of individual and unit-related factors associated with increased odds of non-response based on HCV screening in the general population in Poland

OBJECTIVES

Response rate in public health programmes may be a limiting factor. It is important to first consider their delivery and acceptability for the target. This study aimed at determining individual and unit-related factors associated with increased odds of non-response based on hepatitis C virus screening in primary healthcare.

DESIGN

Primary healthcare units (PHCUs) were extracted from the Register of Health Care Centres. Each of the PHCUs was to enrol adult patients selected on a random basis. Data on the recruitment of PHCUs and patients were analysed. Multilevel modelling was applied to investigate individual and unit-related factors associated with non-response. Multilevel logistic model was developed with fixed effects and only a random intercept for the unit. Preliminary analysis included a random effect for unit and each of the individual or PHCU covariates separately. For each of the PHCU covariates, we applied a two-level model with individual covariates, unit random effect and a single fixed effect of this unit covariate.

SETTING

This study was conducted in primary care units in selected provinces in Poland.

PARTICIPANTS

A total of 242 PHCUs and 24 480 adults were invited. Of them, 44 PHCUs and 20 939 patients agreed to participate. Both PHCUs and patients were randomly selected.

RESULTS

Data on 44 PHCUs and 24 480 patients were analysed. PHCU-level factors and recruitment strategies were important predictors of non-response. Unit random effect was significant in all models. Larger and private units reported higher non-response rates, while for those with a history of running public health programmes the odds of non-response was lower. Proactive recruitment, more working hours devoted to the project and patient resulted in higher acceptance of the project. Higher number of personnel had no such effect.

CONCLUSIONS

Prior to the implementation of public health programme, several factors that could hinder its execution should be addressed.

Clarifying the PSA grey zone: The management of patients with a borderline PSA

INTRODUCTION

Prostate specific antigen is a marker for prostate cancer and a key diagnostic tool, yet when to refer patients with a borderline PSA is currently unclear. This review describes how to assess a patient with borderline PSA and provides an algorithm for management.

METHODS

Current literature on reference values, factors affecting PSA, indications for referral, non-invasive investigations and the role of MRI were reviewed. Medline and EMBASE were searched using MeSH terms.

RESULTS

The literature suggests that a PSA of over 1.5 ng/mL should be used as a cut-off to consider further testing for all age groups. There is strong evidence to show that adjuncts are useful when interpreting PSA results, most notably percentage free PSA and proPSA. Considerable weighting should also be given to the ERSPC risk calculator when deciding when to refer. Multi-parametric MRI is valuable in closely examining suspicious lesions to reduce the number of negative biopsies. MRI fusion biopsy (TRUS, transrectal ultrasonography or transperineal) should be considered over standard TRUS biopsy to detect more clinically significant disease.

CONCLUSIONS

Management of borderline PSA is not straightforward. A cut-off of 1.5 ng/mL should be used in conjunction with digital rectal exam, risk calculation and PSA adjuncts. Imaging and biopsy should utilise mpMRI to achieve improved diagnosis of clinically significant prostate cancer, with fewer unnecessary investigations.