PSA—Screening Guidelines and Background

The United States Preventive Services Task Force (USPSTF) changed their PSA screening guidelines from “PSA screening is of no value” (2012) to “PSA screening is of value” (May 8, 2018). This review of PSA screening guidelines is intended to provide insight and clarification.

These guidelines are from the USPSTF and the American Urology Association.

CURRENT PSA SCREENING GUIDELINES

  1. 2018 Men aged 55 to 69 at average risk of developing prostate cancer
  2. Men over age 70 who are expected to live 10 years and have an increased risk of developing prostate cancer
  3. Men aged 45 who have an increased risk of developing prostate cancer: African Americans and those men with one first degree relative with prostate cancer OR who have first degree relatives who have died of cancer of the breast, ovary or pancreas
  4. Men aged 40 with 2 or more first degree relatives with prostate cancer—the highest risk group

RISK FACTORS FOR DEVELOPING PROSTATE CANCER

  1. African Americans: twice the risk of developing prostate cancer.
  2. Men with one first degree relative (father or brother) with prostate cancer: twice the risk of developing prostate cancer. The risk increases with 1 or more family members who died of prostate cancer.
  3. Men who have a first degree relative who died from cancer of the breast, ovary, or pancreas: increased risk of developing prostate cancer.
  4. Men with multiple first degree relatives with prostate cancer—these men are in the highest risk group.

NOTES

  1. The most reliable indicator of prostate cancer is PSA Velocity. The PSA should increase by ~ 0.1 per year. An increase of 0.5 per year is a “Risk Count”. Each time this occurs the risk of developing prostate cancer increases 50%.
  2. Screening intervals can be every two years, especially if the PSA is less than 1.0. “Interval cancers” (cancers detected between screening events) are rare.

BACKGROUND

The first article to prove that PSA was of value in detecting early prostate cancer was published in 1991. This article and FDA approval resulted in PSA screening being widely used in the detection of prostate cancers that would not otherwise be found and detection of prostate cancer at earlier stages.

The effect:

  1. A decrease in the mortality rate from prostate cancer
  2. Detection of prostate cancers at a much earlier stage—when curable
  3. Detection of some prostate cancers that did not need to be treated due to low volume and low grade

DEVELOPMENTS IN PSA SCREENING RECOMMENDATIONS

In 2012 the USPSTF stated that PSA screening was of no value in the early detection of prostate cancer and was associated with significant harms. They recommended all PSA screening be abandoned.

In 2013 an American Urology Association distinguished panel stated:

  • PSA screening is most beneficial in men age 55 to 70 All men for whom
  • PSA screening is recommended should be counseled about the benefits and the potential risks

In the years between 2012 and 2018 the 20-year decline in prostate cancer mortality plateaued. In addition, there has been a significant increase in men presenting with high volume and metastatic prostate cancer who cannot be cured.

In May 2018 the USPSTF reversed their 2012 recommendation and stated that “PSA screening is of value in the age group 55 to 69”

PSA SCREENING—SHARED DECISION MAKING

Men who are appropriate candidates for PSA screening are informed that PSA screening has potential benefits: an increased cure rate due to earlier detection.

  • An elevated PSA can lead to the recommendation to obtain a prostate biopsy. A prostate biopsy takes about ~ 30 minutes to perform and intravenous sedation is commonly used so that there is no discomfort.

Prostate biopsies have risks that are relatively minor:

  • Infection—The risk of infection has been reduced. The nation-wide risk of infection is approximately 4%. With the use of two antibiotics Roper urologists have decreased this risk to approximately 2%. Currently a study is being done that has shown that the risk of infection can be reduced to 0.03%, a reduction from 2 in 100 biopsies to 1 in 300 biopsies.
  • Bleeding in the urine or in the stool is a risk that is minor and generally resolves in 1-2 days

CAUSES OF AN ELEVATED PSA

PSA can be elevated for several reasons:

  • Prostate cancer
  • Inflammation of the prostate (prostatitis)
  • Prostate size: the PSA level depends on the size of the prostate. Men with larger prostates have PSA levels that are higher than men with smaller prostates

WHAT IS THE RISK OF DEVELOPING PROSTATE CANCER

Prostate cancer is the most common cancer in men (after skin cancer) and the second most common cause of cancer death in US men.

In 2018 approximately 170,000 men will be diagnosed with prostate cancer and approximately 30,000 men will die from prostate cancer. The average risk is 17% in US men or 1 in 6.

These are guidelines. PSA screening remains inexpensive and can be useful in evaluation prostate problems. With the patient’s agreement and after a review of the potential benefits and minor risks, physicians will hopefully be more comfortable be more comfortable discussing PSA screening with their patients.