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.