Smarter Screening and Treatment (S3T): Mitigating Harm via Age- and Prostate-Specific Antigen-Stratified Screening

Consensus on optimal prostate cancer screening remains elusive. Prostate-specific antigen (PSA) testing of patients in their 40-50 s is highly predictive of aggressive disease, yet remains underutilized; Black patients face excess mortality burden, particularly at younger ages. We describe a novel age and baseline PSA-stratified protocol to mitigate harms of overdiagnosis and reduce burden of disease, particularly for Black patients, with implementation by primary care providers (PCPs) in an academic healthcare system.

We developed an evidence-based, age- and baseline PSA-stratified protocol and disseminated it to PCPs via talks and written materials beginning in 2016, with implementation as a health maintenance banner in the electronic health record (EHR) in 2019. EHR data were searched for rates of PSA screening within the prior 5 years in patients aged 40-90 from 2015 to 2021. We examined associations between age and race with receipt of PSA testing over time. Multivariable hierarchical mixed effects regression was performed to identify testing predictors, with clinic and provider included as nested random effects.

Across 99,994 encounters, guideline-concordant PSA screening increased from 32.7 to 45.8% from 2015 to 2021 (p < 0.001) despite COVID-19. PSA screening among Black patients aged 40-75 increased from 29.7 to 52.8% by 2021, with notable gains among younger Black patients. In a mixed effects model, Black patients were more likely to undergo PSA screening (OR 1.35, 95% CI 1.29-1.42). Screening was less likely in geriatric clinics, and there was a wide range in screening (0-75%) rates across individual PCPs.

Multidisciplinary collaboration, PCP outreach, and an EHR-based intervention improved PSA-based screening, particularly for younger Black patients. Significant provider variation in screening rates persists, suggesting the need for continued PCP engagement.