Are we ordering too many PSA tests? Prostate cancer diagnosis and PSA screening patterns for a single Veterans...

Limits on the frequency of PSA testing and an endpoint for the age of the screened population have not been established. The numbers of performed serum PSA tests, cost evolution, and utilization patterns by various subspecialties in one medical center were analyzed to gain insight into trends in screening for early detection of prostate cancer and gather information about the appropriate use of PSA testing.

Computerized records were reviewed for numbers of PSA tests obtained, prostate biopsies performed, and prostate cancer cases diagnosed in the VA NJ-Health Care System from 1996 to 1998. In addition, PSA tests performed during two representative weeks in 1996 and 1997 were analyzed to evaluate a smaller cohort of patients with regard to age, consequences of the test results in their management, and subspecialties ordering the tests.

PSA testing increased steadily between 1992 and 1998, with the most significant change (152% increase) between 1997 (9,410 tests) and 1998 (23,684). Prostate cancer diagnoses by biopsy were 164/434 (37.8%) in 1997 and 195/507 (38.5%) in 1998. For the 14,274 additional PSA tests obtained in 1998, 31 more prostate cancers were diagnosed. Prostate cancer diagnoses per PSA tests were 164/9,410 (1.8%) in 1997 and 195/23,684 (0.8%) in 1998. Primary care providers ordered 61% of the PSA tests.

Most PSA tests at this institution were ordered by general practitioners, and the number of PSA tests ordered for men over 75 was high. The dramatic increase between 1997 and 1998 was not accompanied by a similar rise in the diagnosis of prostate cancer, raising the possibility of indiscriminate PSA testing or unnecessary repetition of testing. Guidelines for prostate cancer screening and continued PSA testing in the geriatric population may need further clarification.