This is the first systematic review of the literature focusing on follow-up policy after a normal or elevated PSA test by GPs and non-urologic hospitalists. Only 15 studies were published on this topic, most of which were of low quality. Furthermore, a large variety of opinions and policies used by general practitioners and non-urologic hospitalists were described on follow-up after a normal or an abnormal PSA test result. Only four studies researched cut-off values for referral or repeat testing. Reasons for repeating a PSA test after an initial normal result were not described (although two studies described testing PSA yearly). Only one study mentioned the reasons for not referring patients after an abnormal PSA test. A time frame for repeating a test was mentioned in none of the studies. Therefore, the strongest conclusion of this systematic review is that there is a large variety in follow-up after primary PSA testing.
Selection of studies and quality assessment
We conducted this systematic review according to the proposed guidelines . We believe that our search strategy was adequate, because we used broad search terms and only one additional study was included after checking the reference lists of the included studies. A limitation of this study is the small number of studies that was found and the exclusion of one Japanese study due to language restrictions.
We have arbitrarily chosen a cut-off value of 75% for the definition of high quality studies. We could not apply quality scores in further analyses, due to the wide variety of PSA testing policies and the few data this generated. Therefore, we refrained from pooling the data and performing meta-analyses.
The interpretation of our results may be limited to the differences in study design. Database studies may describe follow-up policies more accurately than survey studies do, as the latter may include socially acceptable answers instead of describing the physicians’ true actions. The number of studies included was too small to uncover this - expected - effect of study design on the results.
Referral after normal PSA test
After a normal PSA test around 7-10% of the patients are referred to a urologist in all physician groups. Referral after an initially normal PSA value seems to have decreased over time, described by database studies in the USA [14, 21] and survey studies in UK [22, 23]. A possible explanation for this finding is that patients may be referred for other reasons than the PSA value, for instance because of the presence of therapy resistant LUTS.
Referral after moderately abnormal PSA test (PSA ≥ 4 ng/ml)
Non-urologic hospitalists appeared to refer more patients after an abnormal PSA test than GPs, but seem to refer about as often as PCPs. Only one study described follow-up by non-urologic hospitalists, but this study also showed quite high referral rates for GPs .
More patients were referred in the USA [14, 16, 19, 21, 25] than in Spain . These differences between countries may reflect differences in local guidelines. Until 2009 the AUA guideline on PSA testing recommended PSA testing for patients 50 years or older with a life expectancy of 10 years or more , while the EAU guideline does not recommend such screening behavior .
In the USA, referral rates differed over time (1995–1998) [14, 16, 19, 21], which could not be explained by a change in guidelines, but might be explained by the different designs of these four studies.
In the included survey studies a small group of about 20% of physicians report only referring after a PSA value > 10 ng/ml [15, 17, 20]. All guidelines advise to follow-up an elevated PSA value, but do not mention how or when follow-up after an abnormal PSA test should be conducted.
Only one study mentioned the reasons for not referring after an abnormal PSA test. The main reason was that the PSA value was considered too low, but comorbidity also played a role. Another reason might be that the interpretation and further management of abnormal test results are strongly affected by the physicians' estimation of pretest disease probability . It is not mentioned if these patients underwent repeat testing. By not conducting follow-up testing physicians seem to imply that an abnormal PSA value holds no consequences for these patients. Maybe these PSA tests could have been omitted, because knowing your PSA value to be elevated, can cause a lot of (unnecessary) distress in patients .
Repeat testing after normal PSA test
Repeat PSA testing after a normal PSA test varied greatly. It seemed to be widely used in the USA (as recommended by the AUA guidelines) as well as in the UK [22, 25], and to a lesser extent also in France , which is not in accordance with the EAU guidelines. At least two studies (one UK, one USA) reported that physicians agree with screening by an annual PSA test [22, 25], which is not in accordance with the European guidelines.
All of the studies included and all of the reported guidelines were published before the recent presentation of the ERSPC and the publication of the results of the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial. Before the publication of the ERSPC and PLCO results there was no clear evidence on the effect of PSA testing. This resulted in different opinions and consecutively different guidelines on PSA testing, not only between but also within countries. The ERSPC showed that PSA-based screening may reduce prostate cancer mortality by 20%, but it remained unclear which patients may benefit from screening . However, the PLCO trial did not show a mortality reduction . Also, a recent meta-analyses on the effect of population based screening showed no significant effect on mortality . We believe that these studies are important to take into account when considering PSA testing in men who request this. Recently, the US Preventive Services Task Force postulated a negative advice on PSA testing .
In survey studies, participants may provide desirable answers, which are not in line with their daily practice. We have found no study to support this suggestion.