Prostate Cancer New Guidelines For PSA Screening

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Main Category: Prostate / Prostate Cancer
Also Included In: Urology / Nephrology;  Medical Devices / Diagnostics
Article Date: 27 Apr 2009 - 10:00 PDT

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The American Urological Association (AUA) issued new guidelines on prostate cancer screening for men today, which goes against much of the recent advice of other groups, and recommends that well informed men aged 40 and over who have a life expectancy of at least 10 years should be offered the prostate-specific antigen (PSA) test in order to establish a baseline reading and that PSA testing should be individualized rather than a blanket annual test for any man aged 50 and over.

There has been a lot controversy lately about when men should start regular PSA screening, how often, and at what point should a biopsy be indicated.

The AUA said that when offered and interpreted appropriately, the PSA test helps doctors diagnose, assess risk, and stage prostate cancer pre-treatment, and then monitor progress afterwards.

The AUA has updated its Best Practice Statement, which was first issued in 2000, to include new recommendations about who should undergo PSA screening, and if and when a biopsy should be done following an abnormal reading. (A biopsy involves taking tissue samples of the prostate to see if any cancer tumors are present and if so how aggressively they are growing and spreading.)

The main change to the statement is the recommendation that well informed men aged 40 and over who have a life expectancy of 10 years or more should have the option to go in for early detection and risk assessment for prostate cancer, comprising a PSA test and a digital rectal exam (DRE, where the doctor inserts a finger into the patient's rectum to see if the prostate feels normal).

The AUA are making this recommendation because after reviewing recent studies, they concluded that a baseline PSA level that is above the median (the mid-range) for men at age 40 is a strong predictor for prostate cancer.

Testing at the much earlier age of 40 (the recommended age from most other groups is testing should start around 50), said the AUA, allows more curable cancers to be found earlier, and may also allow for less frequent and more efficient testing thereafter.

Men who wish to be screened should be offered a PSA test and a DRE, and in order to better assess risk, doctors should also take into account their patients' family history, overall health, ethnicity and age, said the AUA's new guideline.

Doctors should also discuss the pros and cons of screening, such as the possibility of over-detection, whereby cancers that don't need attention right now might show up; this can cause patients to worry unnecessarily, for example.

Dr Peter Carroll, chair of the AUA panel that developed the Statement said the most important message of the new guideline is that:

"Prostate cancer testing is an individual decision that patients of any age should make in conjunction with their physicians and urologists."

He said there was no single universal standard that you can apply to all men, and nor should there be, given the current tools available. He also said that the panel looked at all the recently reported trials of PSA testing in the US and Europe before issuing the Statement.

"The strengths and limitations of these trials are reviewed in the guideline," he added.

One of the controversial areas is if and when a biopsy should be done.

The AUA said there is a continuum of risk, at all values of PSA. In other words you can't say to a patient that there is a threshold PSA value below which a biopsy will not detect prostate cancer.

Instead, the decision as to whether to do a biopsy or not should not rely solely on the PSA reading(s), but should also take into account a range of other factors, such as free and total PSA, PSA velocity and density, the age of the patient, family history, ethnicity/race, other illnesses/diseases, general health, and previous biopsy history.

PSA (prostate specific antigen) is a protein made almost exclusively in the prostate. Free PSA is PSA that is not bound to other proteins, and it is believed that the more free PSA a man has, the less likely it is that he has prostate cancer. PSA velocity is the rate at which the levels go up over a period of regular testing. However, not all prostate cancers progress at the same rate or are life-threatening, so the PSA reading is only one factor in the decision to do further diagnostics and/or treatment.

The decision should be one that men discuss in detail with their urologists, said the AUA. Some may decide to treat, others may decide to wait and watch. The decision should be an individual one, they said, as Carroll explained:

"Prostate cancer comes in many forms, some aggressive and some not."

"But the bottom line about prostate cancer testing is that we cannot counsel patients about next steps for cancer that we do not know exist."

He also said the AUA will revise and update the guidelines in the light of any new evidence and research.

-- AUA.

Written by: Catharine Paddock, PhD
Copyright: Medical News Today
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