UPDATE - Issue 36 - Spring 2009
Inequalities in PSA testing
When a patient has a PSA test, if the result is above a certain cut-off level, further tests will probably be needed. If it is below that level the patient is reassured with regard to the likelihood of having prostate cancer.
Bristol based researchers sent a questionnaire regarding PSA cut-off levels to urologists in the UK. 47% replied, giving rise to some interesting findings.
The Department of Health (DoH) published recommended cut-off levels in 2002. The most commonly used age-related PSA cut-off values are, however, somewhat higher than the Department of Health recommendations. In addition, it was apparent that lower PSA cut-off values are being used in private practice as opposed to the National Health Service. The results are shown in the table.
Not only is there a difference between the cut-off levels the DoH recommends and those actually being used, there are also large regional variations. Respondents to the researchers questionnaire came from ten regions. One region had 44% of its urologists following DoH guidelines whilst another had just 7%. Why should this be? A lack of awareness of the guidelines may well be a factor. However a majority of urologists were aware of the Department of Health’s PSA related guidelines but less than a third were using them in clinical practice in 2008. Perhaps a more significant factor, mentioned by several participants is the paucity of evidence supporting the recommended age-related PSA cut-offs.
Whatever the reason, we deplore these variations in the application of the PSA cut-off values among urologists. They may lead to inequality in men’s healthcare related to PSA testing. Furthermore, additional problems arise when GPs are working to different cut-off levels from the consultants to whom they refer patients. The transition of patients between primary and secondary care needs to be as efficient as possible - something facilitated if both urologists and GPs are working to the same referral guidelines.