General practitioners' reflections on using PSA for diagnosis of prostate cancer. A qualitative study

OBJECTIVE

To investigate how GPs use the PSA test as a diagnostic tool in daily practice.

DESIGN

Qualitative study using focus group interviews, the transcripts being analyzed by systemic text condensation.

SUBJECTS

A total of 17 Norwegian GPs in three CME groups.

MAIN OUTCOME MEASURES

Exploring GPs' attitudes to national guidelines and the practical use of the PSA test.

RESULTS

Detecting prostate cancer in general practice is a common and important, but difficult diagnostic issue. Our participants experienced uncertainty regarding the test when to use it, how to interpret the results and when to refer to specialist health services.

CONCLUSION

The study revealed a general ambivalence to the use of PSA. Many patients present urological problems, and many are afraid of having cancer. PSA is commonly used, but sometimes generates problems rather than solving them.

IMPLICATIONS

The use of the PSA test should be based on a thorough clinical assessment and in close collaboration with the patient.Key pointsMany patients in general practice present urological problems, and many are afraid of having cancer.GPs have a general ambivalence to the use of PSA when to use it, how to interpret the results and when to refer to specialist health services.The use of PSA sometimes generates problems rather than solving them.

Effects of replacing PSA with Stockholm3 for diagnosis of clinically significant prostate cancer in a healthcare system - the Stavanger experience

OBJECTIVE

To describe early experience of replacing PSA with Stockholm3 for detection of prostate cancer in primary care.

DESIGN AND METHODS

Longitudinal observations, comparing outcome measures before and after the implementation of Stockholm3.

SETTING

Stavanger region in Norway with about 370,000 inhabitants, 304 general practitioners (GPs) in 97 primary care clinics, and one hospital.

INTERVENTION

GPs were instructed to use Stockholm3 instead of PSA as standard procedure for diagnosis of prostate cancer.

MAIN OUTCOME MEASURES

Proportion of GP clinics that had ordered a Stockholm3 test. Number of men referred to needle biopsy. Distribution of clinically significant prostate cancer (csPC) (Gleason Score ≥7) and clinically non-significant prostate cancer (cnsPC) (Gleason Score 6), in needle biopsies. Estimation of direct healthcare costs.

RESULTS

Stockholm3 was rapidly implemented as 91% (88/97) of the clinics started to use the test within 14 weeks. After including 4784 tested men, the percentage who would have been referred for prostate needle biopsy was 29.0% (1387/4784) if based on PSA level ≥3ng/ml, and 20.8% (995/4784) if based on Stockholm3 Risk Score (p < 0.000001). The proportion of positive biopsies with csPC increased from 42% (98/233) before to 65% (185/285) after the implementation. Correspondingly, the proportion of cnsPC decreased from 58% (135/233) before to 35% (100/285) after the implementation (p < 0.0017). Direct healthcare costs were estimated to be reduced by 23-28% per tested man.

CONCLUSION

Replacing PSA with Stockholm3 for early detection of prostate cancer in primary care is feasible. Implementation of Stockholm3 resulted in reduced number of referrals for needle-biopsy and a higher proportion of clinically significant prostate cancer findings in performed biopsies. Direct healthcare costs decreased. KEY POINTS A change from PSA to Stockholm3 for the diagnosis of prostate cancer in primary care in the Stavanger region in Norway is described and assessed. •Implementation of a new blood-based test for prostate cancer detection in primary care was feasible. A majority of GP clinics started to use the test within three months. •Implementation of the Stockholm3 test was followed by: -a 28% reduction in number of men referred for urological prostate cancer work-up -an increase in the proportion of clinically significant cancer in performed prostate biopsies from 42 to 65% -an estimated reduction in direct health care costs between 23 and 28%.