Unawareness of partner risk factors thwarts implementation of USPSTF recommendations for HIV pre-exposure prophylaxis in primary care

The United States Preventive Services Task Force recommends pre-exposure chemoprophylaxis for persons at high risk of HIV exposure. The optimal screening strategy for at-risk individuals in primary care is not known. We evaluated the strategy of universal screening and discussed challenges to the implementation of this recommendation in primary care. Around 430 of 500 (86%) screening surveys were completed. Mutual monogamy was common but monogamous partners with recent negative HIV testing were uncommon. Likewise, among heterosexually active men and women, inconsistent condom use was common. Such individuals would be on guideline for HIV pre-exposure prophylaxis (PrEP) if their partner was at risk for HIV exposure. None of these potentially at-risk individuals met the criteria for PrEP, but 13% lacked knowledge of their partners' sexual and behavioral risk factors, preventing a clear decision on whether PrEP should be used. Our screen identified no individuals who clearly met the guideline criteria for HIV PrEP. We conclude that universal screening for HIV PrEP in primary care is unlikely to be an efficient strategy; targeted screening is likely more appropriate. Moreover, the 2019 guidelines for heterosexually active men and women rely on information that is often unknown to the patient, which makes these guidelines difficult to implement. Future guidelines should address these problems.

Increasing aggressive prostate cancer

INTRODUCTION

To compare prostate biopsy (Pbx) characteristics, before and after the 2012 United States Preventive Services Task Force (USPSTF) prostate cancer screening guidelines in our practice.

MATERIALS AND METHODS

We completed a retrospective comparative analysis of 1703 sequential patients that had a Pbx in 2010 to 2012 (3 years) with 1006 patients biopsied in 2018, 2019 and 2021 (3 years). Data from a total of 2709 Pbx was collected on patient age, race, prostate-specific antigen (PSA), digital rectal examination (DRE) and Gleason sum score (GSS). The data was analyzed to determine whether the 2012 USPSTF screening recommendations against prostate cancer screening may have affected prostate cancer characteristics. Two study groups were defined as Group A and Group B. Group A represents Pbx prior to the 2012 USPSTF screening guidelines (2010-2012) and Group B represents Pbx in 2018-19 and 2021. The patient population consisted of 76% Black, 14% White and 11% other.

RESULTS

The number of patients that had a Pbx in Groups A vs. B: 567 patients/year vs. 335 patients/year. The annual positive Pbx rate for Group A vs. B: 134/year vs. 175/year. High grade prostate cancer (GSS 7-10) in Groups A vs. B: 51.5% vs. 59%. The proportion of patients with a PSA 10 ng/mL or greater in Groups A vs. B: 25.4% vs. 31%. The PSA 10 ng/mL and over and GSS 7-10 was higher in Group B for all age groups. In 2021, GSS 7-10 was present in 64% of 70-80 year olds. In Group B, GSS 6 decreased by 7.5% while GSS 7-10 increased by 7.5% compared with Group A.

CONCLUSIONS

Our data through the year 2021 shows that after the 2012 USPSTF recommendations against prostate cancer screening, Pbx decreased and prostate cancer diagnosis and high grade (GSS 7-10) prostate cancer increased. As our patient population consists of 76% Black patients and 33% of men age 70-80 years old, our results support annual prostate cancer screening for US men 50-80 years old and especially high-risk patients that include Black men, men with a family history of prostate cancer and healthy men age 70-80 years old. Annual DRE- and PSA- based prostate cancer screening will likely markedly decrease prostate cancer morbidity, mortality and the cost of prostate cancer management.

Guideline based eligibility for primary prevention statin therapy - Insights from the North India ST-elevation myocardial infarction registry (NORIN-STEMI)

BACKGROUND

Current risk scores to estimate atherosclerotic cardiovascular disease (ASCVD) risk and allocate statins in at-risk persons have largely been developed in Western populations; their applicability in India is uncertain.

OBJECTIVE

To assess eligibility for primary prevention statin therapy using the 2018 U.S Multisociety Guideline and other contemporary cholesterol guidelines in patients presenting with ST-elevation myocardial infarction (STEMI) in the North India STEMI (NORIN-STEMI) registry.

METHODS

NORIN-STEMI registry prospectively enrolled 3,635 patients at 2 tertiary care centers in Delhi, India from January 2019 to February 2020. Pooled cohort risk equations were used to estimate ASCVD risk at presentation. Patients were evaluated for statin eligibility using the 2018 U.S Multisociety Guideline, United States Preventive Services Task Force (USPSTF), and National Cholesterol Education Program (NCEP) III cholesterol guidelines.

RESULTS

A total of 2,551 met the inclusion criteria. The median age was 54 years; 17% were women. The median ASCVD risk was 7.0%. At the time of MI, 54% of patients were eligible for primary prevention statin therapy by Multisociety Guideline, 46% by USPSTF, and 30% by NCEP III guidelines. These findings were applicable in both women and men. Compared with patients aged ≥50 years, those <50 years were less likely to be recommended statin therapy by all the three guidelines.

CONCLUSION

A significant proportion of patients with STEMI in India did not meet the current guideline-based threshold for statin therapy for primary prevention. Novel risk stratification tools are needed to identify patients for primary prevention statin therapy in this population.

Brief Report: Risk Prediction Model Versus United States Preventive Services Task Force 2020 Draft Lung Cancer Screening Eligibility Criteria-Reducing Race Disparities

Introduction

Eligibility criteria for lung cancer screening based solely on age and smoking history are less sensitive than validated risk prediction models. The U.S. Preventive Services Task Force (USPSTF) has proposed new guidelines to improve the sensitivity for selecting high-risk individuals and to decrease race disparity. In this retrospective study, termed the Chicago Race Eligibility for Screening Cohort, we compare the sensitivity of the proposed USPSTF2020 criteria versus the PLCOm2012 risk prediction model for selecting a racially diverse lung cancer population with a smoking history for lung cancer screening.

Methods

This Chicago Race Eligibility for Screening Cohort study applies the PLCOm2012 model with a risk threshold of 1.0%/6 years and the USPSTF2020 criteria (age 50-80 y, pack-years ≥ 20 y, quit-years ≤ 15 y) to 883 individuals with a smoking history diagnosed with having lung cancer.

Results

The PLCOm2012 was more sensitive than the USPSTF2020 overall (79.1% versus 68.6%, p < 0.0001) in White (81.5% versus 75.4%, p = 0.029) and in African American (82.8% versus 70.6% p < 0.0001) individuals. Of the total cohort, 254 (28.8%) would not have qualified owing to less than 20 pack-years, quit-time of more than 15 years, and age less than 50 years. Of these 254 cases, 40% would have qualified by the PLCOm2012 model. For the 20 pack-year criterion, of the 497 African American individuals, 19.3% did not meet this criterion, and of these, an additional 31.3% would have qualified by the PLCOm2012 model (p = 0.002).

Conclusions

Although more sensitive than USPSTF2013, the proposed USPSTF2020 draft guidelines still have a race disparity in eligibility for screening. This study provides "real world" evidence that use of the PLCOm2012 risk prediction model eliminates this race disparity.

Risk Prediction Model Versus United States Preventive Services Task Force Lung Cancer Screening Eligibility Criteria: Reducing Race Disparities

INTRODUCTION

Disparities exist in lung cancer outcomes between African American and white people. The current United States Preventive Services Task Force (USPSTF) lung cancer screening eligibility criteria, which is based solely on age and smoking history, may exacerbate racial disparities. We evaluated whether the PLCOm2012 risk prediction model more effectively selects African American ever-smokers for screening.

METHODS

Lung cancer cases diagnosed between 2010 and 2019 at an urban medical center serving a racially and ethnically diverse population were retrospectively reviewed for lung cancer screening eligibility based on the USPSTF criteria versus the PLCOm2012 model.

RESULTS

This cohort of 883 ever-smokers comprised the following racial and ethnic makeup: 258 white (29.2%), 497 African American (56.3%), 69 Hispanic (7.8%), 24 Asian (2.7%), and 35 other (4.0%). Compared with the USPSTF criteria, the PLCOm2012 model increased the sensitivity for the African American cohort at lung cancer risk thresholds of 1.51%, 1.70%, and 2.00% per 6 years (p < 0.0001). For example, at the 1.70% risk threshold, the PLCOm2012 model identified 71.3% African American cases, whereas the USPSTF criteria only identified 50.3% (p < 0.0001). In contrast, in case of whites there was no difference (66.0% versus 62.4%, respectively [p = 0.203]). Of the African American ever-smokers who were PLCO1.7%-positive and USPSTF-negative, the criteria missed from the USPSTF were those with pack-years less than 30 (67.7%), quit time of greater than 15 years (22.5%), and age less than 55 years (13.0%).

CONCLUSIONS

The PLCOm2012 model was found to be preferable over the USPSTF criteria at identifying African American ever-smokers for lung cancer screening. The broader use of this model in racially diverse populations may help overcome disparities in lung cancer screening and outcomes.

A Trend Toward Aggressive Prostate Cancer

To compare prostate biopsy (Pbx) characteristics before and after the 2012 United States Preventive Services Task Force (USPSTF) prostate cancer (PCa) screening guidelines, we completed a retrospective comparative analysis of 1703 sequential patients that had a Pbx in 2010 to 2012 (3 years) with 383 patients biopsied in 2018 and 310 patients biopsied in 2019. Data was collected on patient age, race, serum prostate specific antigen (PSA) level, digital rectal examination (DRE) results, total number of biopsies performed, and Gleason sum score (GSS). Data were analyzed to determine whether the 2012 USPSTF screening recommendations against PCa screening may have affected PCa characteristics. Three study groups were defined as Group A, Group B, and Group C. Group A represents Pbx prior to the 2012 USPSTF screening guidelines (2010-2012), Group B represents Pbx in 2018, and Group C represents Pbx in 2019. The patient population consisted of 73% Black men, 16% White men, and 11% men of other races. The number of patients that had a biopsy in Groups A through C, respectively, were 567 patients/year, 383 patients/year, and 310 patients/year. The annual positive Pbx rate for Group A through C was 134/year, 175/year, and 201/year, respectively. High-grade PCa (GSS 7-10) in Groups A through C was 51.5%, 60.5%, and 60.0%. The proportion of patients with a serum PSA level 10 ng/mL or greater in Groups A through C was 25.4%, 29.3%, and 33%. For patients age 70 to 80 years, there was an increasing trend for serum PSA levels 10 ng/mL and higher: 31%, 38%, and 39%, respectively. In this age group, high-grade tumors (GSS 7-10) occurred in 61%, 65%, and 68%, respectively. In 2019, Grade Group 3, 4, and 5 was present in 37.7% of 70- to 80-year-old men and 34.6% of Black men. More than 50% positive biopsy cores were present in 46.3% of 70- to 80-year old men and 36.6% of Black men. Our data through 2019 continued to show that after the 2012 USPSTF recommendations against PCa screening, PCa screening has decreased. We found decreased Pbx, increased PCa diagnosis, and increased high-grade PCa (GSS 7-10). As our patient population consisted of 73% Black patients and 33% of men age 70 to 80 years, our results support aggressive PCa screening for high-risk patients, which include Black men, men with a family history of PCa, and healthy men age 70 to 80 years.

Prostate Biopsy Features: A Comparison Between the Pre- and Post-2012 United States Preventive Services Task Force Prostate Cancer Screening Guidelines With Emphasis on African American and Septuagenarian Men

We compare prostate biopsy (Pbx) characteristics from 3 years prior to the 2012 United States Preventive Services Task Force (USPSTF) prostate cancer (PCa) screening guidelines with those of 2018, with a focus on African American (AA) men and healthy men aged 70 to 80 years. We completed a retrospective comparative analysis of 1703 sequential patients that had had a Pbx from 2010 to 2012 (3 years) with 383 patients biopsied in 2018. Data was collected on patient age, race, prostate-specific antigen (PSA), digital rectal examination (DRE), total number of biopsies performed, and Gleason sum score (GSS). The data was analyzed to determine whether the 2012 USPSTF screening recommendations affected PCa characteristics. Two study groups were defined as group A and B, Pbx prior to the 2012 USPSTF screening guidelines and that of 2018, respectively. The study population consisted of 71% high-risk AA patients. In Group A (pre-2012 USPSTF guidelines), 567 patients/year underwent a Pbx versus Group B, 383 patients/year, a 32% reduction post-USPSTF. The annual positive Pbx rate for Group A is 134/year versus Group B with 175/year, a 31% increase post-USPSTF. In Group B, there was a 94% relative increase in total positive biopsies. Group A had high-grade PCa (GSS 7-10) in 51.5% versus 60.5% in Group B, a 9% increase post-USPSTF. The proportion of patients with a PSA 10 ng/mL or higher was 25.4% in group A versus 29.3% in group B. The age group of 70 to 80 years demonstrated an increasing trend for patients with PSA 10 ng/mL and higher, 31% in Group A versus 38% in Group B; high-grade tumors (GSS 7-10) occurred in 61% in Group A versus 65% in Group B. After the 2012 USPSTF guidelines against PCa screening, our study shows decreased prostate cancer screening with decreased Pbx, increased PCa diagnosis, and increased high-grade (GSS 7-10) PCa. These trends were especially notable in the 70- to 80-year age group, which showed a larger proportion of total patients (compared with pre-2012 USPSTF guidelines), increased PCa grades, increased PSA levels, and a higher percentage of patients with greater than 50% positive cores. As our patient population consists of 71% AA patients, our results support aggressive PCa screening for high-risk patients, which includes AA men, men with a family history of PCa, and healthy men aged 70 to 80 years.

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.

Prostate Biopsy Characteristics: A Comparison Between the Pre- and Post-2012 United States Preventive Services Task Force (USPSTF) Prostate Cancer Screening Guidelines

To compare prostate cancer (PCa) characteristics diagnosed by prostate biopsy (Pbx) in the 3 years before and after the 2012 United States Preventive Services Task Force (USPSTF) recommendations for PCa screening, we completed a retrospective comparative analysis of 402 sequential PCa patients diagnosed from 2010 to 2012 (3 years) with 552 PCa patients diagnosed from 2015 to 2017 (3 years). Data was collected on patient age, race, total number of biopsies performed, prostate specific antigen (PSA), Gleason sum score (GSS), and digital rectal examination (DRE). The data was analyzed to determine whether the 2012 USPSTF screening recommendations affected PCa characteristics. Two study groups were defined, Group A and Group B, prior to and after the 2012 USPSTF screening recommendations, respectively. In Group A (pre- 2012 USPSTF recommendations), 567 patients/year underwent a Pbx versus Group B, 398 patients/year, a 30% reduction post-USPSTF. The annual positive Pbx rate for Group A is 134/year versus Group B 184/year, a 37.3% increase post-USPSTF. Group A had high-grade PCa (GSS 7-10) in 51.5% versus Group B in 60.1%, an 8.6% increase post-USPSTF. In Group B, the total number of positive biopsies was increased by 100%. This study shows that in Group B, the Pbx rate decreased by 30% but the annual PCa detection rate increased by 37%. High-grade GSS (7-10) PCa increased by 8.6%. Despite a reduction in the total number of prostate biopsies by 30%, there was a 100% increase in the total number of positive prostate biopsies.

The impact of the United States Preventive Services Task Force (USPTSTF) recommendations against prostate-specific antigen (PSA) testing on PSA testing in Australia

OBJECTIVE

To assess the impact of the United States Preventive Services Task Force (USPTSTF) recommendations on prostate-specific antigen (PSA) testing, prostate biopsy, and prostatectomy in Australian men based on the available Medicare data.

PATIENTS AND METHODS

Events were identified using Medicare item numbers for PSA testing (66655, 66659), prostate biopsy (37219), prostatectomy (37210), and prostatectomy with lymph node dissection (37211). The occurrences of each procedure was queried per 100 000 capita for consecutive financial years over the period 2000-2015. For each item number, reports were also generated for all Australian States. For PSA testing the data was stratified into three age groups of 45-54, 55-64, and 65-74 years. For assessing the rate of prostatectomy the capita rate values for two item numbers of prostatectomy (37210) and prostatectomy with lymph node dissection (37211) were combined.

RESULTS

Steady declines in per capita incidences of all five item numbers assessed were seen for the three consecutive financial years (2013-2015) since the publication of the USPTSTF recommendation statement. These declines were seen across all Australian States. When examining the rate of PSA testing for the three age brackets 45-54, 55-64, and 65-74 years, similar trends were identified.

CONCLUSIONS

Since the introduction of the USPTSTF recommendation statement there has been a steady nationwide decline in per capita incidences of PSA testing, prostate biopsy, and prostatectomy based on the Australian Medicare data. Whether these declines are in the right direction toward reduction in over-diagnosis and overtreatment of clinically insignificant prostate cancer or stage migration toward more locally advanced disease due to lost opportunity in diagnosing and treating early clinically significant prostate cancer will remain to be seen.

Receipt of mammography recommendations among White and non-White women before and after the 2009 United States Preventive Services Task Force recommendation change

PURPOSE

Receipt of a mammography recommendation from a physician is a strong predictor of obtaining a mammogram. In 2009, the United States Preventive Services Task Force (USPSTF) recommended routine biennial mammography for women aged 50-74 but not for women aged 40-49. We examined changes in reports of clinician recommendations for mammography among White and non-White women after these age-specific recommendations were issued.

METHODS

Data from women aged 40-49 and 50-74 were drawn from the 2008 and 2013 National Health Interview Surveys. We used linear probability models to determine whether the proportions of women reporting a mammography recommendation changed after the USPSTF recommendation was issued and whether any changes observed differed across White and non-White women. All analyses were stratified by age groups and mammography history.

RESULTS

Among women without a recent mammogram, reported clinician recommendations did not change for White women, but they decreased by 13-percentage points (95 % CI -0.22, -0.03) among non-White women aged 40-49 (p = 0.01) and increased by 9-percentage points (95 % CI 0.01, 0.17) among non-White women aged 50-74 (p = 0.04). Among women with a mammogram in the past 2 years, reported mammography recommendation from a clinician did not change for White or non-White women.

CONCLUSIONS

Recommendations to reduce screening may be differentially implemented across racial/ethnic groups. Changes in reports of mammography recommendation from a clinician after the USPSTF breast cancer screening recommendation change were observed only among non-White women without a recent history of mammography. It is unclear whether these differences are due to the clinician, the women, or both.

The politics of prostate cancer screening

The controversial recent recommendation by the United States Preventive Services Task Force (USPSTF) against prostate-specific antigen (PSA) screening for early-stage prostate cancer has caused much debate. Whereas USPSTF recommendations against routine screening mammography in younger women resulted in fierce public outcry and eventual alteration in the language of the recommendation, the same public and political response has not been seen with PSA screening for prostate cancer. It is of paramount importance to ensure improved efficiency and transparency of the USPSTF recommendation process, and resolution of concerns with the current USPSTF recommendation against PSA screening for all ages.

Primary care physician PSA screening practices before and after the final U.S. Preventive Services Task Force recommendation

OBJECTIVES

In May 2012, United States Preventive Services Task Force (USPSTF) finalized its recommendation against prostate-specific antigen (PSA) screening in all men. We aimed to assess trends in PSA screening frequency amongst primary care physicians (PCPs) surrounding the May 2012 USPSTF recommendation.

METHODS AND MATERIALS

The electronic data warehouse was used to identify men aged between 40 and 79 years with no history of prostate cancer or urology visit who were evaluated by an internal medicine or family practice physician between 2007 and 2012. Analyses were directed toward PSA testing within 6-month time period from June to November, with particular focus on the 2011 (pre-USPSTF recommendation) and 2012 (post-USPSTF recommendation) cohorts. The primary outcome measure was proportion of men with at least 1 PSA test during the 6-month pre- and post-USPSTF recommendation periods.

RESULTS

A total of 112,221 men met inclusion criteria. There was a significant decrease in screening frequency between the 2011 and 2012 cohorts (8.6% vs. 7.6%, P = 0.0001; adjusted odds ratio 0.89, 95% confidence interval 0.83-0.95). This decrease was most evident amongst patients aged 40 to 49 years (5.6% vs. 4.6%, P = 0.004) and 70 to 79 years (7.9% vs. 6.2%, P = 0.01). A significant decrease was also observed in patients with highest previous PSA value<1.0 (P<0.0001) and 1.0 to 2.49 ng/ml (P = 0.0074).

CONCLUSIONS

Since the USPSTF recommendation was finalized, there is evidence of continuing decreases in PSA testing by PCPs. PCPs may be shifting toward more selective screening practices, as decreases in screening are most pronounced in the youngest and oldest patients and in those with history of PSA values<2.5 ng/ml.