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  • There are several guidelines that provide circumstances

    2019-08-16

    There are several guidelines that provide circumstances in which screening is appropriate in younger populations [[1], [2], [3]]. Currently there is inadequate evidence to determine that more intensive screening for higher risk populations produces any long term benefit. While the evidence in this Calcipotriol is poor, retrospective studies show that earlier and more intensive screening in high-risk populations may be beneficial [21]. With this in mind, screening in a younger man with risk factors for prostate cancer including family history or African American race should not be definitively characterized as low-value as the evidence is unclear. However, our results suggest that much of the screening performed in men younger than 55 was not driven by documented risk factors. While the relative difference in percentage of documented risk factors within the younger age group compared to the reference 55–69 age group was statistically different, the absolute difference of 4.1% is not likely clinically meaningful. Additionally, only a quarter of men screened at age 45 or less had documented risk factors for prostate cancer. Of note, the CDC estimates an individual’s risk of developing prostate cancer from age 40–49 to be 0.31% [22]. The short between-testing interval identified in this study is also concerning. Studies leveraging population based data suggest that extending screening intervals beyond one year results in higher value testing with respect to both cost and reduction in identification of clinically irrelevant cancers [[23], [24], [25]]. The AUA, NCCN, and ACS each provide recommendations regarding screening intervals which are designed to allow longer between-test intervals, especially for men with low PSA values. It is important to note that the median screening interval was slightly longer in men with below median, compared to above median, age-adjusted PSA values. This suggests some providers may be choosing to extend testing intervals based on prior PSA results. Yet this practice appears to be the exception rather than the rule as nearly 85% of tests completed in men with previous PSA values below the median for age are being screened at intervals shorter than 2 years. One of the most consistent positions advocated for in the various guidelines is the importance of considering life expectancy when making screening decisions. It is generally agreed that PSA screening should not be performed in men with a life expectancy of less than 10 years as these men are highly unlikely to experience a benefit from screening and are at the highest risk of overtreatment. We found that 31% of tested men over 70 likely had limited life expectancy based on the CCI. Operationalizing the incorporation of life expectancy into clinical decision making is difficult as no professional society endorses a specific method for determine life expectancy and clinicians do a poor job of estimating complete flower [26]. The CCI can be considered a surrogate for relative health status and life expectancy [16]. While this methodology has not been well-studied, the CCI provides a simple metric based on the information available on retrospective analysis. Regardless, it is clear that providers are not consistently taking patient health status into account when performing PSA testing. Compared to the reference age group, a larger percentage of tests were ordered in men with CCI’s ≥3 in men age 70 or above. This findings suggests that comorbidities and, by inference, life expectancy, is not regularly considered an exclusion for PSA testing in the elderly population. Our study takes an important step towards improving PSA screening by characterizing the current state of PSA screening in a large health system, but there are important limitations to consider. This study was conducted at a single academic institution and these trends my not be generalizable to other centers such as community-based practices or those serving different demographic populations. Importantly, this analysis relied on an accurate and complete family history in the medical record and prostate cancer family history could be missing for some men, thus reducing the rate of risk factors identified in the younger population. Studies have shown family histories are often incomplete [27]. However, the rates of family history found in both those age <55 and in those 55–69 were higher than prevalence studies of the general population, and it seems unlikely that there would be a bias towards less frequent documentation of family history specifically in younger men [28].