1. PSA screening Cost Conscious Project Kristopher Huston January 2016

2. Prostate Cancer Second most common cancer in the U.S. Most prostate cancers are slow growing. Low mortality rate: five-year survival rate is 99%, ten- year survival rate is 98%. Risk factors include advanced age, family history of prostate cancer, and black race.

3. PSA screening PSA is a glycoprotein produced by prostate epithelial cells Nearly 80% of newly diagnosed cases in US are based on initial detection of elevated serum PSA. In pooled analysis by ACA, sensitivity at 4.0 ng/mL cutoff was 21% for detecting any prostate cancer, and estimated specificity was 91%. Source: Wolf AM, et al. American Cancer Society guideline for the early detection of prostate cancer: update 2010. CA Cancer J Clin 2010; 60:70

4. Guidelines for PSA screening American College of Physicians recommend that clinicians have a one-time discussion with average-risk men aged 50 to 69 years to inform them about limited benefits and substantial harms of screening for prostate cancer using the PSA test. When decision is made to screen, PSA test to be performed at intervals ranging from 2 to 4 years.

5. PSA controversy A 2010 meta-analysis of six RCTs comparing PSA screening vs. no screening found no significant difference in overall mortality or disease-specific mortality (1). In 2012, the USPSTF recommended against PSA screening for prostate cancer, based on limited benefit (prevention of 0-1 cancer deaths per 1000 men screened) and substantial harms of screening, including anxiety, biopsy & surgical complications, urinary incontinence, erectile dysfunction. 1.Djulbegovic et al (2010). “Screening for prostate cancer: systemic review and meta-analysis of randomised controlled trials.” BMJ 341: c4543

6. Cost per Test At Long Beach VA, the cost to patient of each PSA serum lab test is $31.31 per Pathology Dept. Lab cost was approximated at $9-10 per test. For Medicare beneficiaries, the mean annual screening cost ranged from $17 to $62 per beneficiary. Annual cost of PSA screening in the U.S. totals at least $3 billion, much of it paid by Medicare and the VA. Source: Ma X., et al. The cost implications of prostate cancer screening in the Medicare population. Cancer 2014 Jan 1;120(1):96-102

7. Methods Chart review of 15 patients seen by resident physician in Long Beach VA clinic during 2015 Record age, number of PSA tests performed, any abnormalities, subsequent evaluation and findings Compare results to ACP guidelines

8. Results Patient AgeNo. of tests, Findings and Complications 73-yo19 tests from ’02-14, all normal 69-yo13 tests from ‘08-15, HIGH: Neg bx 2012 68-yo12 tests from ‘01-15, all normal 61-yo17 tests from ‘97-15, HIGH: No bx, Lost to f/u 65-yo13 tests from ‘02-16, all normal 52-yo10 tests from ‘08-15, all normal 81-yo28 tests from ‘94-15, HIGH: No bx, Never seen by Uro 87-yo7 tests from ‘11-16, HIGH: No bx, Never seen by Uro 74-yo7 tests from ‘95-15, all normal s/p TURP 1997 for BPH 34-yo0 tests

9. Results Patient AgeNo. of tests, Findings and Complications 71-yo9 tests from ‘06-14, all normal 67-yo6 tests from ‘10-15, all normal 51-yo2 tests from ‘13-15, all normal 80-yo8 tests from ‘09-15, all normal 54-yo4 tests from ‘11-15, all normal

10. Summary 40% (6/15) of patients were screened despite age beyond upper limit of recommendation. 155 tests ordered on 15 patients. 27% (4/15) of patients screened positive. One biopsy. No malignancy detected. At $31.31 per test, a total of $4,853 spent on PSA screening for 15 patients.

11. Conclusion PSA screening at the VA clinic in Long Beach is expensive and offers limited clinical benefit. In addition to cost, the test may lead to many infectious and surgical complications from further evaluation. Against ACP guidelines, the test is frequently performed on patients greater than 69 years of age.