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Impact of Prostate-specific Antigen (PSA) Screening Trials and Revised PSA Screening Guidelines on Rates of Prostate Biopsy and Postbiopsy Complications

Abstract

Background

Prostate biopsy and postbiopsy complications represent important risks of prostate-specific antigen (PSA) screening. Although landmark randomized trials and updated guidelines have challenged routine PSA screening, it is unclear whether these publications have affected rates of biopsy or postbiopsy complications.

Objective

To evaluate whether publication of the 2008 and 2012 US Preventive Services Task Force (USPSTF) recommendations, the 2009 European Randomized Study of Screening for Prostate Cancer and the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial, or the 2013 American Urological Association (AUA) guidelines was associated with changes in rates of biopsy or postbiopsy complications, and to identify predictors of postbiopsy complications.

Design, setting, and participants

This quasiexperimental study used administrative claims of 5 279 315 commercially insured US men aged ≥40 yr from 2005 to 2014, of whom 104 584 underwent biopsy.

Interventions

Publications on PSA screening.

Outcome measurements and statistical analysis

Interrupted time-series analysis was used to evaluate the association of publications with rates of biopsy and 30-d complications. Logistic regression was performed to identify predictors of complications.

Results and limitations

From 2005 to 2014, biopsy rates fell 33% from 64.1 to 42.8 per 100 000 person-months, with immediate reductions following the 2008 USPSTF recommendations (−10.1; 95% confidence interval [CI], −17.1 to −3.0; p < 0.001), 2012 USPSTF recommendations (−13.8; 95% CI, −21.0 to −6.7; p < 0 .001), and 2013 AUA guidelines (−8.8; 95% CI, −16.7 to −0.92; p = 0.03). Concurrently, complication rates decreased 10% from 8.7 to 7.8 per 100 000 person-months, with a reduction following the 2012 USPSTF recommendations (−2.5; 95% CI, −4.5 to −0.45; p = 0.02). However, the proportion of men undergoing biopsy who experienced complications increased from 14% to 18%, driven by nonsepsis infectious complications (p < 0.001). Predictors of complications included prior fluoroquinolone use (odds ratio [OR]: 1.27; 95% CI, 1.22–1.32; p < 0.001), anticoagulant use (OR: 1.14; 95% CI, 1.04–1.25; p = 0.004), and age ≥70 yr (OR: 1.25; 95% CI, 1.15–1.36; p < 0.001). Limitations included the retrospective design.

Conclusions

Although there has been an absolute reduction in rates of biopsy and 30-d complications, the relative morbidity of biopsy continues to increase. These observations suggest a need to reduce the morbidity of biopsy.

Patient summary

Absolute rates of biopsy and postbiopsy complications have decreased following landmark publications about prostate-specific antigen screening; however, the relative morbidity of biopsy continues to increase.

Take Home Message

Although there has been an absolute reduction in rates of prostate biopsy and 30-d complications following landmark publications on prostate-specific antigen screening, the relative morbidity of biopsy continues to increase. These observations suggest a need to reduce the morbidity of biopsy.

Keywords: PSA screening, Prostate biopsy, Complications, Guidelines, Randomized trials.

Footnotes

a Department of Urology, Mayo Clinic, Rochester, MN, USA

b Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA

c Division of Cardiology, Yale University School of Medicine, New Haven, CT, USA

d Health Research and Educational Trust, Chicago, IL, USA

e Department of Urology, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Urology Institute, Cleveland, OH, USA

f OptumLabs, Cambridge, MA, USA

Corresponding author. Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA. Tel. +1 507 266 9968; Fax: +1 507 284 4951.

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