Rationale for Baseline PSA Testing Men in their 40s

Categories: Spring 2014
I recently contributed to an article in ONCOLOGY on the pros and cons of baseline PSA testing for men in their 40s. In the article, I argued that available evidence strongly supports using baseline PSA measurements to identify men who are most likely to develop life-threatening prostate cancer later in life.
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© Cissy Lacks

The rationale for baseline PSA testing men in their 40s is based on these principles:

  • PSA measurements in early mid-life identify many men destined to develop metastatic prostate cancer or die from prostate cancer up to 30 years later.

    Evidence supporting this includes a study showing that 44% of all prostate cancer deaths occurred in men with a PSA in the top 10th percentile for their age bracket at age 45-55 years.1

  • The rate of change of a man’s PSA, or PSA velocity (PSAV), can further identify men at high risk for aggressive prostate cancer.

    Evidence supporting this comes from numerous studies: an aging study that showed men had a 50% higher risk of aggressive prostate cancer with a PSA that rose 0.4 ng/ml/year twice or more consecutively (a PSAV “risk count” >1); a screening study that associated men who had a PSAV risk count of >2 with a more than 5-fold increased risk of having the highly aggressive prostate cancer with a Gleason 8-10; a study that found an association between PSAV and prostate cancer-specific mortality after surgery.2

  • Early diagnosis and treatment of aggressive prostate cancer is associated with a lower prostate cancer mortality rate.

    This has been demonstrated in randomized trials3,4 and epidemiologic evidence from national cancer registries.5

Baseline PSA measurements are more accurate predictors of aggressive prostate cancer than race or family history. We cannot fully assess who is at high risk for developing prostate cancer without baseline PSA scores from men in their 40s.

In the PSA screening era, there has been an 80% decrease in the proportion of patients who have metastatic prostate cancer at diagnosis and a 45% decrease in the prostate cancer-specific mortality rate.5 Yet, the use of PSA screening remains controversial because of concerns about the possibility of diagnosing and treating slow-growing cancers that would not cause symptoms if they were left undetected.

In the US, few men currently undergo PSA testing in their 40s. The United States Preventive Services Task Force (USPSTF) and the American Urological Association (AUA) do not recommend that men younger than 55 years undergo PSA screening. These recommendations were largely based on randomized trials that did not include men under age 55 years and had a median follow-up of only about 10 years. However, other guidelines have a different view of baseline PSA testing. The National Comprehensive Cancer Network guidelines recommend offering PSA screening at 40, and the 2013 European Association of Urology guidelines and the Melbourne Consensus Statement recommend baseline PSA testing.

The balance between benefits and risks of PSA testing are individual to each patient. It is important to give men the opportunity to make decisions about assessing their individual risk for prostate cancer through PSA screening.

1 Vickers A. et al. Strategy for detection of prostate cancer based on relation between prostate specific antigen at age 40-55 and long term risk of metastasis: case-control study. BMJ. 2013; 346:f2023; doi:10.1136/bmj.f2023

2 Reviewed in: Loeb S. et al. Prostate-specific antigen velocity (PSAV) risk count improves the specificity of screening for clinically significant prostate cancer. BJU Int. 2012; 109:508-13.

3 Schröder FH. et al. Prostate-cancer mortality at 11 years of follow-up. N Engl J Med. 2012; 366:981-90

4 Hugosson J. et al. Mortality results from the Goteborg randomised population-based prostatecancer screening trial. Lancet Oncol. 2010; 11:725–32

5 http://seer.cancer.gov/faststats/selections.php?#Output (accessed 5/19/2013).

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