Prostate Cancer Screening and Likelihood of Benefit in Veterans Affairs and Fee-for-Service Medicare

Importance Routine prostate-specific antigen (PSA) screening in men with limited life expectancy is low-value care, yet US Department of Veterans Affairs (VA) PSA testing and biopsy rates have not been benchmarked against non-VA care. Objective To determine whether PSA testing and prostate biopsy rates are associated with likelihood of benefit from screening in VA or fee-for-service (FFS) Medicare primary care. Design, Setting, and Participants This retrospective cohort study used national linked VA-Medicare data for fiscal years 2004 to 2023, with up to 20 years of follow up. A 30% random sample of male veterans 65 years or older who were dually enrolled in VA and FFS Medicare Parts A and B were included; men with prior prostate cancer or only Medicare Advantage enrollment were excluded. Exposures Time-varying predominant primary care setting (VA, FFS Medicare, or dual use), assigned from primary care visit distribution across systems over a rolling 36-month window. Main Outcomes and Measures PSA testing and prostate biopsy rates per 1000 person-years. Contemporary incidence rate ratios (IRRs) were estimated with covariate-adjusted Poisson regression and stratified by age and predicted life expectancy. Results Among 1.41 million dually enrolled male veterans (mean [SD] age, 71.3 [7.1] years), 8.67 million person-years were observed. PSA testing declined across settings from 2008 to 2017, with steeper declines in the VA system. From 2018 to 2023, among men 80 years or older, adjusted PSA testing rates were 187.9 vs 267.9 per 1000 person-years in VA primary care vs FFS Medicare (IRR, 0.70; 95% CI, 0.69-0.71), and biopsy rates were 3.38 vs 5.05 (IRR, 0.67; 95% CI, 0.60-0.75). Among men with fewer than 5 years predicted life expectancy, PSA testing in the VA setting was lower (IRR, 0.84; 95% CI, 0.82-0.86). Age- and life expectancy–based differences persisted across sensitivity analyses. In contrast, in the primary analysis, PSA testing in the VA setting was higher among men aged 65 to 69 years (IRR, 1.10; 95% CI, 1.09-1.11). Conclusions and Relevance In this cohort study, compared with FFS Medicare, VA primary care was associated with lower PSA testing and biopsy rates among veterans least likely to benefit, suggesting closer alignment of testing intensity with likelihood of benefit.