Discussion
This is the first work on PCa-ED trends among PCP in Mexico, where currently, PCa is the second most common solid tumour in men over 50 years. The role of PCa-ED is paramount on detecting significant PCa in early stages and it drops the mortality rate up to 21%.2,7,8
Findings related to PCa-ED skills and knowledge are notable, with a low frequency of PCP practising PCa-ED and mostly using concepts which differ from scientific evidence. Despite this, solely a small proportion were self-perceived as “not well-trained” (13.5%, table 1 ).
According to the American Urological Association (AUA) guidelines, PCa-ED is performed through PSA and DRE.9 In this work, 56% of PCP answered carrying out PCa-ED, nonetheless, 61.2% do not perform a single DRE and over 95% perform less than five, monthly. Furthermore, 40% do not test PSA on asymptomatic men, and those who did, mostly selected age ranges outside the evidence-based recommended (figure1 ). Likewise, Tasian et al., reported on 82 PCP from San Francisco, that 86% carry out PCa-ED in <60% of men over 50 years old. However, a survey about PCa-ED practice among PCP from the United Kingdom, found that solely 24% had not tested PSA on asymptomatic men within the last 3 months. Drummond et al., reported a higher rate of PCa-ED practice on 1,625 Irish PCP (79%), although the age ranges also differ from the evidence-based recomendations. These data evidence that the rate of PCP in Mexico performing PCa-ED is low and outside the suggested age ranges. 10–12
On the other hand, PCP scored low in knowledge about PCa risk factors (51.5±15.7%, table 2 ). Factors as older age and a first-degree relative with PCa were correctly identified by >90%, nevertheless, smoking was wrongly identified as a risk factor by a higher rate (84.7%) than that reported elsewhere (29-56%). Although controversial, metanalyses have failed to prove an association of smoking as a risk factor. 10,11,13 Likewise, prostatic hyperplasia was wrongly marked as a risk factor for PCa by 77.6%, whereas solely 28% of the Irish PCP did, even when evidence points otherwise. 10,14 African American race was correctly identified as a risk factor by 49%, whereas Tasian et al., and Drummond et al., reported 98% and 17%, respectively. Furthermore, the rate of PCP self-perceived as “not well-trained” reported by Drummond et al., was more than twice than the herein reported (37% vs 13.5%).10,11
Data suggest a lack of continuing medical education on PCa, nevertheless, our findings, as well as those reported by Tasian et al., showed no association between risk factors knowledge and testing asymptomatic men. 11
Based on these findings, it is important to improve PCP’s training on PCa risk factors, as it might reverberate on better health promotion and PCa prevention, but training focused on clinical skills for PCa-ED is mandatory, since over 28% of PCP were not aware of national guidelines on PCa-ED.
Furthermore, these heterogenic data points that the PCa-ED conducted in Southeast Mexico is suboptimal and of lower rate compared to that reported elsewhere.10,11 This can be partly explained by the high rate of PCP lacking an institutional program or a dedicated clinic to PCa-ED (59.4%) and by the fact of not having access to PSA testing by almost one quarter. Moreover, the rate of PCP who do not carry out DRE was quite high (>60%) and nonetheless the institutional limitations which may prevent them to conduct it such as lack of space, assistance, and time, these were not associated to whether or not performing a DRE (p>0.05)
A PSA >3.0 ng/dL holds a ~25% risk of PCa and a PPV <30% in the PCa-ED. 15,16 More than half of PCP overestimated the PPV of PSA and interestingly, despite the lower rate of DRE conducted, also the PPV of DRE and DRE+PSA was overestimated. Similar results were reported in Malaysia and Ireland, were >50% overestimated PPV from tools used for PCa-ED. A deficient knowledge on this regard carries a risk of overdiagnosis.10,17
Factors related to preventing testing PSA on asymptomatic men on unadjusted model suggest a relation with experience, as PCP who been in practice fewer time or still in training (family medicine residents) were less likely to perform PCa-ED. (table 4 ). This matches with other studies where longer time in practice (>10 years) at least doubled the likelihood of testing PSA on asymptomatic men (OR: 2.15, IC95% 1.11 – 4-16, p=0.03), suggesting that engaging PCP on adequate continuing medical education programs focused on PCa-ED can improve PCa diagnosis. Family medicine residents are trainees, and this hypothetically should have increased the likelihood of testing, nevertheless, other factors as the lack of time due to busy schedules and a supervised decision making by attendings, could have impacted on these results, but furthers studies are needed. 10,17
Multivariate analysis showed that having access to a PSA testing at least triples the likelihood of testing PSA in asymptomatic men (OR: 3.36, IC95%1.5 – 7.30, p=0.002, table 4 ). This result is reasonable and advise that every PCP must have access to PSA testing in their institutions. Drummond et al., reported that PCP having institutional “men clinics” were more likely to test PSA on asymptomatic men. Hence, access to PSA testing, and institutional guidance trough programs or dedicated clinics is a promising strategy for improving PCa-ED in Mexico. Therefore, for PCP currently lacking institutional guidance, a flowchart is provided for PCa-ED decision making (figure 2 ), although further validating studies are needed, and educational-intervention strategies trials are warranted.10
Regardless this work focus on the role of PCP, conducting programs of PCa-ED in Mexico goes beyond in complexity. Additionally, official regulation on PCa-ED is ambitious and yet controversial. A recent insight of PCa-ED in Mexico was published by Lajous et al., and it’s suggested that following the official normativity is challenging as Mexico probably lack the wanted infrastructure and resources to bear the extra burden of around 15 million men undergoing PCa-ED.18 Following the authors’ statements, we consider that outlining a PCa-ED national effort requires not only the PCP topics addressed here but a collective endeavour along health institutions to provide a wider overview and determine the settings needed for this challenging situation.
Some limitations are warned in this work: (i) Southeast Mexico has a high proportion of rural communities, which might not reflect the same situation of other regions; (ii) related literature published arise from non-standardized surveys and questionnaires, hence outcomes are not always uniform and exactly transposable, and (iii) subjecting a patient to PCa-ED is a shared-decision process which requests patients engagement on his own health, a variable which was not considered by this study.