Force (USPSTF) to downgrade their recommendation for prostate
screening in 2012 (2,3). The overall concern of the USPSTF was
that prostate cancer screening was exposing patients to unnecessary
prostate biopsies, leading to overdiagnosis and over-treatment of
clinically insignificant prostate cancer. With the USPSTF downgrade
came a decline in prostate cancer screening; the effects of which
have been noticed within the urologic community.
Follow-up studies into ERSPC and PLCO have exposed potential
design flaws and biases that had urologists questioning the valid-
ity of their outcomes. Control group PSA testing contamination,
screening group compliance issues, and high rates of pre-study PSA
testing have been some of the justified criticisms. Repeat analysis
of ERSPC and PLCO controlling for some of these flaws and bi-
ases has concluded that there was a 25-30% reduction of prostate
cancer specific mortality with PSA screening (4). Additionally,
in the years following the USPSTF downgrade, rates of localized
prostate cancer dropped, while conversely an increased incidence
of late-stage advanced disease was noted (5). These observational
findings sparked the urology community and the USPSTF to refine
their recommendation on screening. Professional societies and
urologists have now collectively decided to bring PSA testing back
into mainstream with supplemental management strategies and
tools to better serve providers and patients.
Instead of screening all adult men, the USPSTF and the National
Comprehensive Cancer Network (NCCN) now recommend indi-
vidualized screening in properly selected men after shared decision
making with their provider. Per NCCN guidelines, PSA and DRE
screening should be offered to men age 45-75 years of age, and only
considered in men >75 years of age if they are very healthy with no
significant comorbid conditions. Referral to a urologist should be
arranged for a rising PSA and/or a PSA > 3ng/mL (or even lower
for those patients at high risk: African-Americans and those with
a strong family history of prostate cancer or BRCA mutations).
Now that prostate cancer screening is back into mainstream,
it remains imperative for urologists to limit unnecessary prostate
biopsies. Historically, an elevated PSA triggered a reflex biopsy. In the
modern PSA era, there are newly developed tools and management
strategies that have been validated to work in conjunction with the
PSA test. Supplemental markers such as percent free PSA, kallikrein,
PCA3, and exosomal RNA have aided urologists and patients in
decision making for acting upon an elevated PSA. In addition to
novel second-line markers, urologists have begun using prostate
MRI to increase the detection rate of clinically significant prostate
cancer. Transrectal ultrasound with MRI fusion technology allows
urologists to more accurately target suspicious lesions concerning
for significant disease as compared to ultrasound guided biopsy
alone. In combination, novel tumor markers and MRI have greatly
MEN'S HEALTH
aided urologists in lowering the rate of unnecessary biopsies while
increasing the detection of clinically significant cancer.
Treatment of prostate cancer in the modern era has also changed.
Essentially all prostate cancer patients with low risk disease are now
offered active surveillance as a viable management strategy. In addi-
tion, genetic profiling of tumor RNA and confirmatory MRI fusion
biopsy are now being widely used to more accurately risk-stratify
patients to support decision making for surveillance. Under close
monitoring with a urologist, a growing number of appropriate cancer
patients are being managed with active surveillance while avoiding
radical treatments such as prostatectomy or radiation.
The gap between prostate cancer prevalence and disease specific
mortality has challenged urologists to properly identify those pros-
tate cancer patients at risk for developing more aggressive disease.
PSA testing has re-emerged as a tool the general provider can use
to screen their adult male patients after shared decision making,
with the understanding that PSA alone is oftentimes not sufficient
to justify a prostate biopsy. Furthermore, a diagnosis of prostate
cancer does not always necessitate radical treatment. Tumor markers,
genetic profiling, MRI and improved biopsy modalities can now be
used in conjunction with initial PSA screening to better manage
our patients. Providers and patients can be reassured that the era
of overdiagnosis and overtreatment of low-risk disease due to an
elevated PSA is now over. The urologic community and professional
societies now know to use these validated tools to supplement PSA
in managing the properly screened patient.
Dr. Kartha practices urology at First Urology in Louisville.
References:
1. Bell KJ, Del Mar C, Wright G, Dickinson J, Glasziou P. Prevalence of
incidental prostate cancer: A systematic review of autopsy studies. Int J
Cancer. 2015;137(7):1749–1757
2. Schröder FH, Hugosson J, Roobol MJ, et al. Screening and prostate-cancer
mortality in a randomized European study. N Engl J Med. 2009;360:1320–
1328.
3. Andriole GL, Crawford ED, Grubb RL, 3rd, et al. Mortality results from a
randomized prostate-cancer screening trial. N Engl J Med. 2009;360:1310–
1319
4. Tsodikov A, Gulati R, Heijnsdijk EAM, et al. Reconciling the Effects of
Screening on Prostate Cancer Mortality in the ERSPC and PLCO Trials.
Ann Intern Med. 2017;167(7):449–455.
5. Hu JC, Nguyen P, Mao J, et al. Increase in Prostate Cancer Distant Me-
tastases at Diagnosis in the United States. JAMA Oncol. 2017;3(5):705–707.
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