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  • Limitations of this study were the absence of

    2019-08-16

    Limitations of this study were the absence of follow-up colonoscopy for negative FIT results (<75 ng/ml) which is related to the study design. As in Flanders (and many other European countries), a colonoscopy is not considered beneficial following a negative FIT as it induces extra risks and is therefore ethically not feasible. The screening programme used the age group 56–74, which does not conform to the European guidelines (50–74). However, multiple countries use this narrower target age for their screening programmes [6]. Considering the recommendation of the EU to include the age range of 50–55, this would most likely increase the ratio between normal and pathological findings after a positive FIT with a subsequent colonoscopy. This means that the chance of performing an unnecessary colonoscopy after a positive FIT would be at least between 50–70% for women within the lower FIT and age range. This strongly suggests evaluating other or additional screening options. Future research should therefore focus on gathering additional risk factors for inclusion in a prediction model by a prospective design. For example, by using a questionnaire with determinants indicated by prior studies such as alcohol intake and BMI [34]. Also of importance is the improvement of the comparability of the data collected from the various national CRC screening programmes. Multiple national CRC screening programmes use different tests, cut-off values, target ages, measurements and even terminology [6]. Belgium can improve this by implementing a colonoscopy registry and report according the international guidelines.
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    Declaration of conflicting interests
    Author statement
    Acknowledgements
    Introduction There are significant differences between professional societies’ recommendations/guidelines for considering PSA testing for early detection of prostate cancer. Guidelines differ in relation to the age at which shared decision making might begin, the between-testing intervals utilized, and the relative impact of Midostaurin (PKC412) and family history on screening decisions [[1], [2], [3], [4], [5]]. Furthermore, the 2012 the United States Preventive Services Task Force (USPSTF) giving prostate cancer screening a “D” recommendation (recommend against) has been recently changed to a “C” recommendation (offer in select patients) for men age 55–69 [4,6]. These changes and inconsistencies leave primary care providers to navigate a difficult and ever-changing landscape in prostate cancer screening and these inconsistencies may contribute to the variation in PSA testing prevalent across the country [7]. One of the more important factors associated with PSA screening is the performance of low-value testing, defined as PSA testing in which the harms outweigh the benefits. While each of the major societal guidelines has differing cutoffs for the definition of low-value testing [[1], [2], [3], [4], [5]], there are some consistent themes: 1) younger men are less likely to benefit from screening, particularly if they do not have risk factors for prostate cancer (e.g. African-American race [8] and family history [9,10]); 2) annual PSA testing likely increases the risks of identifying clinically insignificant cancer without improving the detection of significant cancers compared to longer between-test intervals [11,12]; and 3) men with a life-expectancy less than 10 years are unlikely to benefit from screening due to the long natural history of prostate cancer [13,14]. Yet, within these parameters it is unclear how these are typically incorporated in real world clinical decision making. In this study, we sought to characterize PSA screening patterns in a large academic health system. The primary outcome of interest was the proportion of PSA tests that were low-value based on various professional guidelines. Of note, this does not involve measurement of providers’ performance of shared decision making and only identifies low-value tests that are performed where guidelines recommend against screening entirely. We hypothesized that low-value tests represented a substantial proportion of tests. Secondary outcomes of interest were between-test intervals and the degree to which family history and life expectancy (estimated by age and Charlson Comorbidity index or CCI) [15] factored into screening. We hypothesized that the majority of men undergo repeat screening annually rather than at more extended intervals (irrespective of previous PSA value) and that risk factors and life expectancy are inconsistently factored into screening.