PSA Testing for Prostate Cancer Trends and Variations

Expert Group Meeting on MPV 25-26 April 2013

Annalisa Belloni

OECD Health Division

PSA benefits are controversial

• Early detection and treatment of PC

but

• False negatives and false positive results

• Overdiagnosis and overtreatment

Background – the PSA test

Background – the PSA test

HAS 2012

USPTF 2012

Clinical trials

Guidelines

Aims of the project

• Assess patterns of PSA test use in a selection

of OECD countries

• Assess the role of possible factors associated

with variations

• Explore opportunities for a more efficient use

of tests and coherent use according to the

patient risk

PSA TESTING IN ITALY

Data sources

• Data required:

– Patient characteristics (demographic and clinical

information like diagnosis, symptoms, diagnostic test

and their results)

– Physicians/ practices characteristics (age, sex, and role)

– Geographical area information

• Data used: GP dataset (Health Search)

Trends over Time

0

10

20

30

40

50

60

70

80

90

100

64.00 64.50 65.00 65.50 66.00

To

tal n

um

ber

of

tes

ts

Th

ou

san

ds

Average age at time of test

2009

2010

2000

2001

Change in Average PSA Value

2.4

2.6

2.8

33.2

Ave

rage P

SA

valu

e

0 50000 100000 150000Number of tests

Average PSA value by total number of tests in the year

2000

2001

2002

2009

2008

2010

Regional Differences

0

0.5

1

1.5

2

2.5

3

3.5

0.0% 0.5% 1.0% 1.5% 2.0% 2.5% 3.0% 3.5%

Me

an

PS

A v

alu

e

PSA tests in sample (ratio to regional male population aged>40)

Proportion Tested by Region

25%-35%

35%-45%

45%-56%

Note: 2000-2010, asymptomatic patients

Risk distributions:

0 100%

100%

Coherence curve

Coherence curves:

Coherence Curves

Coherence Curves

Emilia Romagna: proportion tested 60%, tests per patient 4.9

Calabria: proportion tested 45%, tests per patient 3.2

0

10

20

30

40

50

60

70

80

90

100

0 20 40 60 80 100

Emilia Romagna

Calabria

40 y/o, w family history

Variations by GP

05

10

15

20

Pro

port

ion o

f G

Ps

0 .2 .4 .6 .8 1Proportion of patients tested

Distribution of GPs by proportion of patients tested age 40-75

Variations by GP

05

10

15

20

Pro

port

ion o

f G

Ps

0 2 4 6 8Average number of tests per patient

Distribution of GPs by average number of tests per patient

INTERNATIONAL

COMPARISONS IN THE USE

OF PSA TEST

Use of PSA Test in Other Countries

Patients > 75

47.6% in France;

37.8% in the US;

10.7% in the UK

Tuppin et al. 2012

France – Geographical Variations

a) Proportion of men>40 tested by departments

b) Proportion of men>75 tested by departments

Tuppin et al. 2012

Spain – Variations across Practices

0

10

20

30

40

50

60

70

80

90

1 2 3 4 5 6 7 8 9 10

PSA<40/PSA tot

PSA 40-75/PSAtotal

PSA>75/PSAtotal

Data from Lumbreras et al. 2012

Conclusions

• In Italy, use of PSA test increased fourfold during the 2000s

• PSA rates are higher than in the UK, but lower that in the US and France

• Great variability between GPs in test use at least partly explained by different attitudes towards patient risk

Conclusions

• It is possible to identify specific patterns in those attitudes at the regional level

• Even if all tests deemed inappropriate, rationale for policies to cut testing strongest in low risk patients and those at high risk of overtreatment (e.g. >75)

• Regions where testing is more weakly correlated with risk are not those where more tests are done