A trial of risk-adapted prostate cancer screening in a federally supported health center network serving a high-risk population.

backgroundAlthough Black men experience earlier onset and higher mortality from prostate cancer (PCa), no studies to date have tested interventions that encourage adoption of risk-adapted prostate-specific antigen (PSA) screening. The authors conducted a 15-month trial in clinics serving Chicago communities with high PCa mortality and Black population density. Their objective was to determine the impact of "Smart PSA" guidelines on screening behavior and biopsy outcomes.

methodsThrough presentations, in-clinic reminders, and on-site visits, primary care providers (PCPs) were exposed to basic PSA guidelines recommending starting age, repeat test interval, and stopping age, based on race, family history, and baseline PSA. For the intervention period and a matched control period 3 years earlier, the authors extracted data from clinical databases on all visits by men age 35 and over, at six clinics. The primary end point was change in incidence of a screening PSA linked to a PCP encounter.

resultsA total of 4252 and 4022 patients, similar in age and race, had qualifying encounters during intervention and pre-intervention, respectively. PSA screening following encounters increased from 18.7 to 33.0 per 100 patients (Δ = 14.3; 95% CI, 12.4-16.1) with odds ratio = 2.43 (95% CI, 2.17-2.71), adjusted for pre-specified covariates. Guideline compliance was indicated by a larger increase in screening of younger Black patients, and earlier repeat testing after a borderline PSA. Increased screening of men 70 and older indicated potential noncompliance. Biopsy incidence increased from 0.57 to 0.92 per 100 (Δ = 0.35; 95% CI, -0.03 to 0.75), with PCa prevalence at biopsy increasing from 43% to 74%. Total PCa incidence rose 2.7-fold (0.25 to 0.68 per 100, p = .007), with incidence of cancer beyond grade group 1 increasing 3-fold (p = .008).

conclusionThese findings demonstrate that risk-adapted PSA guidelines can be adopted and sustained by PCPs in high-risk settings. Although PCa incidence increased substantially, the predominance of aggressive cancer was unchanged, consistent with the effect of intensified screening in a high-risk population with sparse prior screening for a cancer with long latency. Sustained intensification should eventually cause a new equilibrium, necessitating additional efforts to avoid overdiagnosis.

trial registrationThe trial registration is ClinicalTrials.gov NCT04782713.