Prostate-specific antigen screening, why have the guidelines changed?

Abstract

Prostate cancer (PCa) constitutes a major health issue of the western world given its increasing rate of diagnosis and the fact that it is the second cause of cancer-related death among men. Although the incidence of PCa is rising, deaths from PCa are at the same time declining. This phenomenon has been largely attributed to the implementation of PCa screening. However PCa screening, which is mainly performed through serum prostate-specific antigen measurement, does not have the desired diagnostic accuracy. This results in a substantial proportion of men undergoing unnecessary biopsies and consequently given therapies for low-risk cancers that will have no effect in prolonging life and might as well only add morbidity. The current report will discuss the pros and cons of PCa screening in light of the recent modifications in the guidelines regarding the early diagnosis of PCa.

Keywords::

• early diagnosis
• overtreatment
• prostate cancer
• PSA
• screening
• survival

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the article. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this article.

Key issues

• Prostate-specific antigen (PSA) screening results in an overall increase in the diagnoses of prostate cancer (PCa) and a decrease in cases of PCa diagnosed with advanced and metastatic disease.

• There is still controversy as to whether this rise in PCa diagnosis as a result of screening translates to a decrease in deaths from PCa.

• PSA should be prescribed and interpreted with caution and the indications for biopsy should be drawn taking into consideration the risk factors of the patient in order to avoid unnecessary examinations, biopsies (overdiagnosis) and (over)treatments for a cohort of men with an elevated PSA and ‘low-risk’ prostate cancer.

• PSA screening is recommended for men at risk (family history, African-Americans) between the ages 55 and 70 who have been informed about the risks and benefits of pursuing an early diagnosis (shared decision making).

• Further PSA screening after the age of 70–75 years is not recommended.

• Biannual versus annual PSA screening is now recommended because annual testing does not add to the accuracy of the test and biannual testing does not compromise the early diagnosis of PCa.

• Fusion of MRI with ultrasonography and MRI-guided biopsies will become key in the diagnosis and management of PCa and newer more accurate noninvasive tests (Prostate Cancer Antigen 3, Prostate Health Index and Protoporphyrin IX-PPD) are expected to take the place of PSA as diagnostic tools for prostate cancer.