Association of Prostate-Specific Antigen Screening Rates With Subsequent Metastatic Prostate Cancer Incidence at US Veterans Health Administration Facilities

Abstract

Importance: There is controversy about the benefit of prostate-specific antigen (PSA) screening. Prostate-specific antigen screening rates have decreased since 2008 in the US, and the incidence of metastatic prostate cancer has increased. However, there is no direct epidemiologic evidence of a correlation between population PSA screening rates and subsequent metastatic prostate cancer rates.

Objective: To assess whether facility-level variation in PSA screening rates is associated with subsequent facility-level metastatic prostate cancer incidence.

Design, setting, and participants: This retrospective cohort used data for all men aged 40 years or older with an encounter at 128 facilities in the US Veterans Health Administration (VHA) from January 1, 2005, to December 31, 2019.

Exposures: Yearly facility-level PSA screening rates, defined as the proportion of men aged 40 years or older with a PSA test in each year, and long-term nonscreening rates, defined as the proportion of men aged 40 years or older without a PSA test in the prior 3 years, from January 1, 2005, to December 31, 2014.

Main outcomes and measures: The main outcomes were facility-level yearly counts of incident metastatic prostate cancer diagnoses and age-adjusted yearly metastatic prostate cancer incidence rates (per 100 000 men) 5 years after each PSA screening exposure year.

Results: The cohort included 4 678 412 men in 2005 and 5 371 701 men in 2019. Prostate-specific antigen screening rates decreased from 47.2% in 2005 to 37.0% in 2019, and metastatic prostate cancer incidence increased from 5.2 per 100 000 men in 2005 to 7.9 per 100 000 men in 2019. Higher facility-level PSA screening rates were associated with lower metastatic prostate cancer incidence 5 years later (incidence rate ratio [IRR], 0.91 per 10% increase in PSA screening rate; 95% CI, 0.87-0.96; P < .001). Higher long-term nonscreening rates were associated with higher metastatic prostate cancer incidence 5 years later (IRR, 1.11 per 10% increase in long-term nonscreening rate; 95% CI, 1.03-1.19; P = .01).

Conclusions and relevance: From 2005 to 2019, PSA screening rates decreased in the national VHA system. Facilities with higher PSA screening rates had lower subsequent rates of metastatic prostate cancer. These data may be used to inform shared decision-making about the potential benefits of PSA screening among men who wish to reduce their risk of metastatic prostate cancer.

Figure 1.. Prostate-Specific Antigen (PSA) Screening, Prostate Biopsy, and Prostate Cancer Incidence Rates by Age Group

Long-term nonscreening rates represent the proportion of patients without a PSA screening test in the prior 3 years. All rates were pooled across 128 Veterans Health Administration facilities. Vertical dashed line represents the year of US Preventive Services Task Force screening guideline publication in 2012.

Figure 2.. Prostate-Specific Antigen (PSA) Screening, Prostate Biopsy, and Prostate Cancer Incidence Rates by Racial and Ethnic Group

Long-term nonscreening rates represent the proportion of patients without a PSA screening test in the prior 3 years. All rates were pooled across 128 Veterans Health Administration facilities. “Other” included Asian and Hispanic men. Vertical dashed line represents the year of US Preventive Services Task Force screening guideline publication in 2012.

Figure 3.. Association of Prostate-Specific Antigen Screening Rates and Long-term Nonscreening Rates With Subsequent Metastatic Prostate Cancer Incidence

Predicted case count estimates were generated from multivariable mixed-effects negative binomial models using a random effect of 0, continuous covariates at their mean values, Pacific region, and facility size of 40 889 men. Shaded areas indicate 95% CIs.