Introduction: Over screening for prostate cancer can result in unnecessary laboratory costs, patient anxiety, and unnecessary biopsies. Thus, prostate cancer screening should be avoided in very low-risk populations for whom the potential harms of overdiagnosis and overtreatment greatly outweigh potential benefits. One such population is men who have a serum prostate specific antigen (PSA) < 1 ng/mL on or after their 60th birthday. In the Malmo Prevention Project, this group of men was found to have a 0.5% lifetime risk of developing metastatic prostate cancer and 0.2% risk of death from prostate cancer. These findings were confirmed in the Southern Community Cohort Study of 22,905 Black men, where 97% of aggressive prostate cancer cases occurred in men whose PSA was above the age-specific mean – 0.94 ng/mL for men aged 55-59 and 1.03 ng/mL for men 60-64 years. Therefore, continued PSA screening in this population should be discouraged. The objective of this study was to determine the rates of continued PSA testing in men > 60 years with serum PSA < 1 ng/mL.
Methods: We retrospectively reviewed our Enterprise Data Warehouse for all men = 60 years old with a serum PSA < 1 ng/mL seen in primary care practices from 1/1/2014 – 9/10/2021. This included 156 care locations in North and South Carolina. Men were excluded if they had a diagnosis of prostate cancer recorded in the electronic health record. Prostate specific antigen testing was determined through laboratory data. Subsequent testing was defined as a resulted PSA after a man had a serum PSA < 1 ng/mL at or after age 60. Clinical and demographic data were collected for all men, including age and race.
Results: There were 36,392 men 60 years or older with serum PSA < 1 ng/mL. Of these men, 26,079 (71.7%) had subsequent PSA testing, with a mean of 2.2 additional PSA tests per patient ordered during the study period. In total, an excess of 80,798 PSA tests were conducted in this very low risk cohort. Subjects who had repeat testing differed significantly from those who did not on race, with white men undergoing repeat testing more often than Black men (73% vs 67%, p < 0.001).
Conclusions: Men with a serum PSA < 1 ng/mL at age 60 or later continued to undergo PSA screening at very high rates. This leads to very high levels of excess PSA tests being performed, which can result in wasted healthcare spending and potential unnecessary patient anxiety. Further study on interventions to discourage continued PSA testing in this population is warranted.
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