Recent prostate cancer screening recommendations from the US Preventive Services Task Force (USPSTF) and the American Urological Association (AUA) suggested that PSA testing for prostate cancer should be restricted in certain age groups or stopped altogether, resulting in confusion regarding the role of PSA testing in the early detection of prostate cancer. Consequently, many primary care physicians and internists are no longer ordering routine PSA tests in their patients.
New International Guidelines
The latest screening recommendations released by experts at the Prostate Cancer World Congress and the European Association of Urology (EAU) offered a different perspective. They emphasized that early detection reduces the number of men dying from prostate cancer and developing metastatic disease, and PSA testing is a key element of screening.
Melbourne Consensus Statement
Experts at the Prostate Cancer World Congress in Melbourne, Australia, created a consensus statement on PSA testing to address the conflicting recommendations of various urological groups. The statement highlighted the importance of shared decision-making and the significant improvement in prostate cancer survival rates since the introduction of PSA testing 20 years ago. The authors wrote that an important goal for early detection is to maintain these survival rate gains while minimizing the harms associated with overdiagnosis and overtreatment.
New EAU Guidelines
The updated EAU guidelines emphasized early detection of prostate cancer through an individualized, riskadapted approach rather than widespread mass screening. Baseline PSA testing is an integral component of the guidelines, as is identifying relevant risk factors that can be used to classify patients into risk groups.
“Abandonment of PSA testing as recommended by the USPSTF, would lead to a large increase in men presenting with advanced prostate cancer and a reversal of the gains made in prostate cancer mortality over the past three decades.”
–Melbourne Consensus Statement
Melbourne Consensus Statement
- PSA testing for men ages 50-69 reduces deaths and frequency of metastatic prostate cancer
The authors recommend shared decision-making rather than routine population-based screening.
- Prostate cancer diagnosis needs to be uncoupled from treatment
Active surveillance strategies need to be standardized and validated internationally to ensure the safety of this treatment approach.
- PSA testing is part of the approach to early detection
Variables such as digital rectal examinations, prostate volume, family history, ethnicity and risk prediction models can help determine a man’s risk level. New tools such as the prostate health index (PHI) test and further developments of biomarkers may also enhance risk prediction.
- A baseline PSA is useful for predicting future risk of prostate cancer
The higher a man’s baseline is above the median (0.5–0.7 ng/ml at 40- 49 years), the greater his risk of later developing life-threatening prostate cancer.
- Men with a life expectancy of more than 10 years may still benefit from PSA testing
Individualized assessment, rather than age alone, should determine if PSA testing for an older man would be useful.
The Melbourne Consensus Statement was published online by BJU International. Dr. Catalona is a signatory on the statement.
- Early detection reduces prostate cancer deaths and the risk of being diagnosed with metastatic and advanced prostate cancer
- A baseline PSA should be obtained at 40-45 years of age
A baseline PSA above the median might be a better indicator of prostate cancer development than other risk factors, such as race and family history.
- Testing intervals should be adjusted according to the baseline PSA
Men with a PSA above 1.0 ug/l at 45–59 years of age should be screened every 2-4 years. Men with a PSA below this level could have a screening interval up to 8 years.
- PSA screening should be offered to men with a life expectancy of 10 or more years
A man’s life expectancy, rather than his age, should be considered when discussing prostate cancer screening or treatment.
- In the future, risk-prediction tools need to be part of the decision-making process
Multivariable risk-prediction tools such as risk calculators, clinical parameters such as new serum or urinary biomarkers, and the identification of specific genetic mutations associated with prostate cancer could help identify high-risk patients.
The guidelines were published by European Urology in June.