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Introduction Prostate cancer screening using prostate‐specific antigen (PSA) testing remains widespread. The prevalence of PSA testing in young men is unknown and may be an appropriate target for improving health care by decreasing low‐value testing in this age group. The purpose of this study was to determine PSA testing rates in men younger than current guidelines support. Materials and Methods Health Informational National Trends Surveys (HINTS) from 2011 to 2014 and 2017 were analyzed to establish the prevalence of PSA testing in young men and to evaluate the differences in testing rates based on race. Results The combined survey data included 5178 men, with 2393 reporting previous PSA screening. Of men ages 18–39, 7% recalled receipt of PSA testing. Twenty‐two percent of men between the ages of 40 and 44 had been tested. Among men under age 40, PSA testing was more common among black men (14%) compared to white men (7%), Hispanics (6%), and men of Asian descent (8%). Logistic regression modeling demonstrates that black men under the age of 40 were more likely to undergo PSA testing than other racial or ethnic groups (odds ratio 2.14; 95% CI 1.17, 3.93). Conclusions Current guidelines do not recommend routine PSA testing in average‐risk men under the age of 40. This study found that a significant number of young men are exposed to testing, with the greatest risk among black men. This suggests that there is an opportunity to improve the value of PSA testing by decreasing testing in young men., Health Informational National Trends Surveys were analyzed to establish the prevalence of PSA testing in young men and to evaluate the differences in testing rates based on race. We found that a significant number of young men are exposed to testing, with the greatest risk among black men. These results suggest there is an opportunity to improve the value of PSA testing by decreasing testing in young men, and thereby decrease premature exposure to the emotional and financial burden of false positives and the physical risks of diagnostic testing and treatment.

INTRODUCTION: Encouraging the appropriate use of staging imaging in patients with newly diagnosed prostate cancer remains a challenge. Assessing the effects of national efforts may help guide future initiatives in curtailing low-value care. The purpose of this study was to determine the impact of the Choosing Wisely campaign on imaging utilization among men with prostate cancer. METHODS: Surveillance, Epidemiology, and End Results – Medicare data were used to complete a longitudinal population-based study of men diagnosed with prostate cancer from 2007 to 2015. An interrupted time series analysis evaluated the impact of the Choosing Wisely campaign on trends of imaging utilization. RESULTS: From 2007-2015 imaging utilization in low-risk patients decreased, with computed tomography (CT) usage declining from 45.0% to 34.4% (p

INTRODUCTION AND OBJECTIVE:Sarcopenia (low skeletal muscle mass) is a poor prognostic factor in patients undergoing nephrectomy for localized renal cancer. However, little is known about the trajec...

INTRODUCTION AND OBJECTIVE:Methods that embrace the complexity of prostate cancer (CaP) gene expression are necessary for accurate phenotypic characterization. We previously presented a novel agnos...

BACKGROUND Low-value prostate-specific antigen (PSA) testing is common yet contributes substantial waste and downstream patient harm. Decision fatigue may represent an actionable target to reduce low-value urologic care. The objective of this study was to determine whether low-value PSA testing patterns by outpatient clinicians are consistent with decision fatigue. METHODS Outpatient appointments for adult men without prostate cancer were identified at a large academic health system from 2011 through 2018. The authors assessed the association of appointment time with the likelihood of PSA testing, stratified by patient age and appropriateness of testing based on clinical guidelines. Appointments included those scheduled between 8:00 am and 4:59 pm, with noon omitted. Urologists were examined separately from other clinicians. RESULTS In 1,581,826 outpatient appointments identified, the median patient age was 54 years (interquartile range, 37-66 years), 1,256,152 participants (79.4%) were White, and 133,693 (8.5%) had family history of prostate cancer. PSA testing would have been appropriate in 36.8% of appointments. Clinicians ordered testing in 3.6% of appropriate appointments and in 1.8% of low-value appointments. Appropriate testing was most likely at 8:00 am (reference group). PSA testing declined through 11:00 am (odds ratio [OR], 0.57; 95% CI, 0.50-0.64) and remained depressed through 4:00 pm (P

PURPOSE Germline likely pathogenic or pathogenic variants (PVs) have been identified in up to 17% of men with prostate cancer (PC) and may drive disease severity or be targetable by novel therapies. National Comprehensive Cancer Network (NCCN) guidelines encouraging germline testing in metastatic PC were recently expanded to include all men with high-risk, very high-risk, or regional PC. Our aim was to assess the impact of expanded NCCN guidelines on the detection rate of germline PVs and to determine patient-level factors associated with a PV germline testing result. PATIENTS AND METHODS Men with PC underwent multigene germline genetic testing for PVs from June 2016 to December 2018, and trends were compared. The association of patient-level factors with a PV germline testing result, where ≥ 1 PV was identified, was assessed using analysis of variance and univariate logistic regression. Sensitivity analyses were limited to clinically actionable variants and those associated with disease severity or progression ( BRCA1/2 and ATM). RESULTS Of 408 men undergoing germline testing, 42 (10.3%) men had PVs and 366 (89.7%) men did not have PVs identified. The proportion of men identified with a germline PV remained stable following testing criteria expansion (9.4% v 10.6%, P = .73). No patient-level factors were significantly associated with increased odds of a PV germline testing result, including age at diagnosis, race, pretreatment prostate-specific antigen, Gleason grade group, NCCN risk group, and family history of cancer (breast and/or ovarian, prostate, or any cancer). CONCLUSION This study demonstrated a stable PV detection rate in men with PC using expanded criteria aligned to the updated NCCN testing guidelines. However, we did not find strong evidence to suggest that patient-level factors are associated with PV germline testing results. These findings support the recent expansion of NCCN germline testing guidelines in PC.

RESEARCH OBJECTIVE: Low‐value prostate‐specific antigen (PSA) testing is responsible for substantial waste and potential harm to patients, yet it accounts for nearly half of prostate cancer (PCa) screening. Decision fatigue, the progressive decline in consistency and quality of choices with repetitive decision making, has been observed in breast and colorectal cancer care. Our aim was to determine whether low‐value PSA testing patterns by outpatient providers are consistent with decision fatigue. STUDY DESIGN: Outpatient encounters across various specialties were stratified by clinical guidelines as whether a PSA test order would be appropriate or low value. The primary endpoint was whether a PSA test was ordered. Logistic generalized estimating equations were used to analyze PSA test likelihood by appropriateness, with spline functions representing trends by hour. Models were adjusted for patient‐, provider‐, and appointment‐level factors and stratified by specialty. POPULATION STUDIED: Men without PCa at a large academic health system from July 2011 to June 2018 were identified. In total, 1,761,815 outpatient visits were completed by this cohort of men during the specified time period. PRINCIPAL FINDINGS: Of these 1,761,815 outpatient encounters, a PSA test was ordered during 3.7% when it would be considered appropriate and 1.8% when it was low value. The overall likelihood of an encounter resulting in any PSA test was greatest at 8:00am, tapering off by 12:00pm (OR = 0.66; 0.58–0.75) and persisting at this nadir through 4:00pm (OR = 0.65; 0.56–0.77). Testing patterns differed between specialties, with nonurologists exhibiting a proportionately greater decline in the likelihood of ordering an appropriate test as the day progressed. Urologists showed a different pattern, with appropriate decisions relatively preserved throughout the day even as inappropriate testing declined in the middle of the day. CONCLUSIONS: In a framework where PSA testing decisions are considered complex and the default position is to not test, PSA testing among nonurologists is consistent with decision fatigue. That is, testing is most likely early in the day when complex decisions are easiest. The pattern of PSA testing among urologists is different and may not be explained by decision fatigue. This may be due to differences in the default position for testing or greater PSA testing expertise, which lightens the cognitive load of decision making. IMPLICATIONS FOR POLICY OR PRACTICE: Future efforts to improve value and reduce waste in PSA testing might employ clinical decision support, which has been shown to be an effective intervention in the setting of decision fatigue. Interventions should ideally be tailored to each specialty’s unique needs. PRIMARY FUNDING SOURCE: National Institutes of Health.

PURPOSE: A life course perspective to cancer incidence is important for understanding effects of the environment during early life on later cancer risk. We assessed spatial clusters of cancer incidence based on early life location defined as 1940 US Census Enumeration District (ED). METHODS: A cohort of 260,585 individuals aged 0–40 years in 1940 was selected. Individuals were followed from 1940 to cancer diagnosis, death, or last residence in Utah. We geocoded ED centroids in Utah for the 1940 Census. Spatial scan statistics with purely spatial elliptic scanning window were used to identify spatial clusters of EDs with excess cancer rates across 26 cancer types, assuming a discrete Poisson model. RESULTS: Cancer was diagnosed in 66,904 (25.67%) individuals during follow-up across 892 EDs. Average follow-up was 50.9 years. We detected 15 clusters of excess risk for bladder, breast, cervix, colon, lung, melanoma, oral, ovary, prostate, and soft tissue cancers. An urban area had dense overlap of multiple cancer types, including two EDs at increased risk for 5 cancer types each. CONCLUSIONS: Early environments may contribute to cancer risk later in life. Life course perspectives applied to the study of cancer incidence can provide insights for increasing understanding of cancer etiology.

25 Background: Previous studies have shown that individuals with cancer who live in rural areas have worse cancer-specific outcomes compared to their urban counterparts. Differences in access to high-quality cancer care and adequate social support may explain some of the observed disparity. Rural patients with relatives in urban areas may have better access to care via an increased ability to navigate the healthcare system than their rural counterparts without relatives in urban areas. In this study, we examine the possibility of a family-based social capital effect on genitourinary cancer survival. We hypothesized that rural patients who have family members living in urban areas have survival outcomes similar to their urban counterparts. Methods: We performed a retrospective cohort analysis of individuals diagnosed with genitourinary cancers, including prostate, bladder, kidney, penile, and testicular cancers. We constructed familial networks using the Utah Population Database (UPDB). Patients were classified as living in either rural or urban areas based on the rural-urban commuting area (RUCA) codes associated with their zip code of residence at the time of cancer diagnosis. Adult first degree relatives (siblings, parents, children) were identified and classified as urban or rural based on the zip code or county of residence at the time of the patients’ diagnosis or, when unavailable, the county or zip code of residence before or after diagnosis. Overall survival (OS) was analyzed using Cox proportional hazards models. Results: We identified 24,746 individuals diagnosed with genitourinary cancer between 1968-2018. Median follow-up was 8.72 years. After adjusting for sex, age, race, cancer type, health improvement index (HII), and Simpson’s diversity index, urban patients had the best OS at 5 and 10 years (reference group). Rural cancer patients without an urban first degree relative had the worst outcomes with OS hazard ratios at five and ten years of 1.4 (CI 1.23-1.58) and 1.4 (CI 1.26-1.55), respectively. Having an urban first degree relative ameliorated much of the urban-rural disparity with five- and ten-year OS hazard ratios of 1.19 (CI 1.07-1.31) and 1.12 (CI 1.03-1.21), respectively. Conclusions: Individuals diagnosed with cancer who live in rural areas have worse survival as compared to their urban counterparts, but this relationship appears to be heavily influenced by the presence or absence of relatives who live in urban areas. Further research is needed to better understand the mechanisms through which having an urban family member may contribute to improved cancer outcomes for rural patients. This may help in the crafting of policies that can reduce urban-rural cancer disparities. Funding: Research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health (K08CA234431 & P30CA042014-31S2). The content does not represent the views of the National Institutes of Health.

240 Background: Debate remains about the value of Prostate-specific antigen (PSA) based prostate cancer screening among men aged 55-69 (USPSTF Grade C). However, no professional society or guideline recommends PSA based prostate cancer screening in men younger than age 40. This study aims to understand the risk of PSA testing exposure in young men, and we hypothesize that substantial low-value testing occurs in this population. Methods: We performed a retrospective analysis of claims data from the MarketScan database to identify men aged 18 to 39 without prostate cancer who received a PSA test from 2008 to 2017. For the primary analysis, men were required to be continuously in the database for least 5 years. Age groups were stratified to include: men less than 25, 25-29, 30-34, and 35-39 years. Secondary analysis did not limit subjects to those with 5 years of continuous data and explored the association of Charlson Comorbidity Index (CCI), lower urinary tract symptoms, erectile dysfunction, depression/anxiety, prostate cancer screening, infertility, and hypogonadism with PSA testing in young men. We used logistic regression to determine which of the factors were associated with PSA testing in young men. Results: We identified claims for 40,164,773 adult men who met study criteria. Of these men, 3,230,748 were continuously in the Marketscan database for at least 5 years. The cumulative risk for receiving a PSA over 5 years for men under 40 is 2.5%. Stratified by age, men aged 35-39 are at highest risk (Table). Logistic multivariable regression showed that, relative to all men between 18 and 40, patients in this age group who received a PSA were more likely to be diagnosed with hypogonadism (OR 20.55, 95% CI 20.39-20.71) or lower urinary tract symptoms (OR 9.34, 95% CI 9.26-9.41). Higher CCIs appeared to correlate with a decreased rate of PSA testing. This population was not significantly more likely to be diagnosed with infertility, depression, or anxiety. Conclusions: PSA screening for men under 40 is not uncommon, especially when associated with concomitant genitourinary symptoms. At a population level, this represents substantial low-value testing. Interventions aimed at clarifying the relationship between common urologic conditions and prostate cancer, the extremely low incidence of prostate cancer in this age group, and the lack of guidelines supporting this practice may help decrease low-value PSA testing. Funding: Research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health under Award Number K08CA234431. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.[Table: see text]

INTRODUCTION AND OBJECTIVE:Low-value PSA testing is responsible for substantial waste and potential harm to patients, yet it accounts for nearly half of prostate cancer (PCa) screening. Decision fa...

Objectives To evaluate various Prostate-Specific Antigen (PSA) thresholds at which a 18F-fluciclovine PET scan could be considered in the setting of biochemical recurrent prostate cancer after definitive treatment. Methods We analyzed available records of men who underwent a 18F-fluciclovine PET scan after definitive therapy at a single academic institution between November 2016 to May 2018. The primary outcome was the rate of positive imaging findings at specific PSA thresholds. We then employed empiric strategies including a ROC curve and decision curve analysis to identify a specific threshold for which obtaining a positive result would be optimized. Results A total of 115 men underwent imaging with 18F-fluciclovine PET. No concerning lesions were identified in 25 (21.7%) patients, 32 (27.8%) had a solitary lesion identified, 45 (39.1%) had 2 to 5 lesions, and 13 (11.3%) had greater than 5 suspicious lesions identified. At PSA thresholds of less than 0.5, 0.5 to 2.0, and greater than 2, lesions were detected in 55.5% (12/22), 70.6% (24/34), and 91.5% (54/59) of patients respectively [P Conclusion This study constitutes an early single institution series evaluating the use of 18F-fluciclovine PET scans in the assessment of biochemically recurrent prostate cancer after definitive treatment. The probability of having positive imaging findings and increasing numbers of suspicious lesions rises with increasing PSA. Utilization of a lower PSA threshold of 0.5 may allow earlier intervention with salvage therapies in biochemical recurrence. However, using a threshold below 1 carries a higher risk of negative scans. Employing a higher PSA threshold of 1 to 2 carries greater sensitivity and specificity and may maximize identifying individuals with early BCR who may benefit from early intervention, while minimizing negative scans.

230 Background: Pathogenic variants (PV) in genes associated with hereditary cancer risk account for over 10% of cases in men with metastatic prostate cancer (PCa). NCCN guidelines encouraging germline testing (GT) in metastatic PCa were recently expanded to include all men with high risk, very high risk, or regional PCa. Previously, we showed that the rate of PV findings did not significantly decrease after expansion of these criteria. In this study, we sought to identify factors associated with a PV finding. Methods: Men with PCa underwent multi-gene GT for PVs from April 2016 – December 2018 according to NCCN guidelines pre- (2016-17) and post-expansion (2018). The association of patient-level factors of interest with a positive GT result, where at least one PV was identified, was modeled with univariate logistic regression while overall model significance was validated with ANOVA. Results: Of 410 men undergoing GT, 44 (10.7%) positive and 366 (89.3%) negative tests resulted. Mean age at diagnosis was 62.2 years. Positive testing remained stable from 9.4% to 11.2% following guideline expansion (p=0.62). None of the patient-level factors of interest were significantly associated with increased odds of a positive GT result in any model generated. These factors included age at diagnosis, race, pretreatment PSA, Gleason grade group, NCCN risk group, and family history of cancer (breast and ovarian, prostate, any cancer). Model p-values ranged from 0.84 for Gleason grade group to 0.12 for family history of any cancer. Conclusions: Future work will need to further elucidate the role of patient-level factors in identifying men with PCa at increased risk for harboring a germline PV. Nonetheless, the lack of identification of other factors associated with positive GT results and a stable PV detection rate of roughly 10% support the recent expansion of NCCN testing guidelines. Given these findings, consideration of even broader NCCN criteria for GT may be justified.