Factors Related to Prostate-Specific Antigen–Based Prostate Cancer Screening in Primary Care: Retrospective Cohort Study of 120,587 French Men Over the Age of 50 Years (Preprint)

Abstract

BackgroundInternational guidelines recommend that PSA-based prostate cancer screening be avoided in elderly patients with a life expectancy shorter than ten years. However, for men aged 50 to 69, most recommendations encourage an individual approach that considers the patient's comorbidities after a shared decision-making process. ObjectiveThe first objective of this study was to assess the inappropriate application of PSA-based prostate cancer screening in men older than 74. The secondary objective was to assess whether the presence (vs absence) of comorbidities was related to PSA testing in younger men eligible for screening (ages 50 to 74). MethodsWe analyzed data from the French national healthcare database (Loire-Atlantique geographic area). We reported the follow-up of two cohorts of men from April 1, 2014 to March 31, 2016; the first included men older than 74 years, and the second included men aged 50 to 74 years.We first analyzed whether these patients received PSA testing after two years of follow-up.We then analyzed whether PSA testing was related to variables such as age, low income, and frailty. Frail individuals were identified by proxy measures illustrative of major comorbidities (repeated ambulance transportation, having one of 30 chronic diseases, having five or more drugs per day) or by proxy measures illustrative of the following specific comorbidities:cancers, cardiovascular diseases, visceral failures, or psychiatric disorders. Statistical analysis was based on a multivariate mixed effects logistic regression. ResultsThe proportion of patients who received a PSA-based screening test was 41.4% (9296 / 22480) among men older than 74 and 41.1% (40275 / 98107) among men aged 50 to 74 (p = 0.41). The following factors were associated with less frequent PSA testing in men older than 74: older age, suffering from a chronic disease, repeated ambulance transportation, diabetes, dementia, psychiatric disorders, and a low income, whereas being treated with cardiovascular drugs was associated with more frequent PSA testing. The following factors were associated with less frequent PSA testing in men aged 50 to 74: suffering from a chronic disease, repeated ambulance transportation, having more than 4 drugs per day, diabetes, psychiatric disorders, being treated by antiaggregant, and having a low income, whereas older age and being treated with other cardiovascular drugs was associated with more frequent PSA testing. ConclusionsIn this study, 41.1% of French men older than 74 had a PSA-based screening test. PSA testing depends on patients' comorbidities. However, PSA testing remains inappropriate in certain populations with major comorbidities (e.g., dementia or visceral failure). Lower screening rates in patients using insulin or with a low income might have no relation to life expectancy.