Prostate-Specific Antigen Screening Patterns and Metastatic Prostate Cancer in US Veterans.

Importance: Metastatic prostate cancer (PC) incidence has increased in US men, partly due to changes in prostate-specific antigen (PSA) screening recommendations. However, few studies have examined contemporary PSA screening practices in large US health care systems. Objective: To describe and examine contemporary PSA testing practices associated with metastatic PC incidence. Design, Setting, and Participants: This cohort study included veterans within the Veterans Health Administration that received a prostate needle biopsy (PNB) between January 2015 and December 2023 with follow-up through 2024, excluding those with a history of PC. Data were analyzed between July 1, 2023, and November 6, 2025. Exposures: PSA tests were retrieved from the VA Corporate Data Warehouse and categorized by age at first VA PSA (<50, 50-59, and ≥60 years) and by longest interval between consecutive VA PSA tests in the 5 years before PNB (≤24 vs >24 months). Clinical, laboratory, pathological, demographic, and census block group-level socioeconomic status data were obtained from the VA Multi-OMICS Analysis Platform for Prostate Cancer database. Main Outcomes and Measures: Multivariable Cox models estimated hazard ratios (HRs) from time of first VA PSA to first PNB, evaluated risk of metastatic (regional or distant) vs localized PC or benign diagnosis, and adjusted for sociodemographic and clinical covariates. Results: There were 103 067 participants of whom 20 233 (19.6%) were younger than 50 years at first PSA, 31 546 (30.6%) were non-Hispanic Black, 58 264 (56.5%) were non-Hispanic White, and 13 277 (12.9%) had other race or ethnicity. Of all participants, 22 190 (21.5%) had a first PSA value of 1 ng/mL or less, 52 939 (51.4%) had a screening interval of 24 months or less, and 3773 (3.7%) were diagnosed with metastatic PC at time of PNB. Compared with men aged younger than 50 years at first PSA, those aged 50 to 59 years (adjusted HR [aHR], 1.27; 95% CI, 1.24-1.29) and 60 years or older (aHR, 2.37; 95% CI, 2.33-2.42) had higher risk of metastatic PC. Men with longer screening intervals had higher risk of metastatic PC (aHR, 1.14; 95% CI, 1.13-1.16). Men aged younger than 50 years with shorter screening intervals had lower rates of metastatic PC (adjusted risk ratio, 0.10; 95% CI, 0.09-0.12) compared with men aged 60 years or older with longer screening intervals. Conclusions and Relevance: In this cohort study, few veterans had the most favorable combinations of screening factors in relation to metastatic PC, suggesting potential for further screening optimization.