The Case For Prostate-Specific Antigen Screening Starting At Age 40

Main Category: Prostate / Prostate Cancer
Also Included In: Urology / Nephrology;  Men's health
Article Date: 13 Oct 2008 - 3:00 PDT

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UroToday.com - Dr. Robert Nadler, of Northwestern University, wrote an excellent editorial in a recent issue of Cancer regarding the commencement of prostate cancer (CaP) screening at age 40.

The National Comprehensive Cancer Care Network (NCCN) recommends an initial PSA at age 40 for men of all races. The frequency of subsequent PSA tests would depend on the initial level. Dr Nadler refers to work by Scales and associates that analyzed data from the 2002 Behavioral Risk Factor Surveillance System. This database is an annual, population-based survey from the Centers for Disease Control that determines the rate of screening in men between the ages of 40 and 50 years. It reports that 22.5% of men ages 40-49 had a PSA test the previous year, compared to 53.7% of men older than 50 years. More African-American men than Caucasian men were screened (33.6% vs. 21.5%).

Nadler believes the data is encouraging in light of the fact that most primary care physicians are not aware of guidelines to screen men at age 40. He points out that a baseline PSA at age 40 serves as a starting point for determining risk. For example, the median PSA level for men in their 40's is 0.7ng/ml and for men in their 50's it is 0.9ng/ml. An age-specific median PSA between 0.7 or 0.9 and 2.5ng.ml results in a 14.6-fold and 7.6-fold increased risk of developing CaP for men in their 40's and 50's, respectively. Carter reported that men with a PSA velocity of 0.35ng/ml/year or greater were 5 times more likely to die of CaP more than 10 years later. Thus, a baseline PSA at age 40 serves as a starting point for determining PSA velocity and detecting CaP in young men at risk. Nadler suggests that to be effective, PSA needs to be measured yearly beginning at age 40, while the NCCN guidelines recommend if the initial PSA is 0.6ng/ml or less, it can next be rechecked at age 45.

Men with a PSA of 4.0ng/ml or higher who undergo radical prostatectomy have a 30% chance of positive surgical margins and thus worse outcomes. Decreasing the PSA threshold for biopsy and treatment to 2.0 or 2.5ng/ml would decrease this risk, Nadler writes.

Finally, he pointed out that the death rate from CaP in the US has decreased from 41,800 in 1997 to 27,050 in 2007. Yet the position that small cancers are unnecessarily treated remains a counterargument. For these men, a diagnosis does not mandate immediate treatment and active surveillance with expectant management can be appropriate. He supports the counterargument with the issues of cost and complications of the biopsy procedure, not to mention the psychological burden of a cancer diagnosis. Yet, in conclusion, the guidelines and rationale for CaP screening beginning at age 40 are well presented by Dr. Nadler, and serve as important information for urologists and primary care physicians.

Nadler RB
Cancer. 2008 Sep 15;113(6):1278-81
10.1002/cncr.23721

Written by UroToday.com Contributing Editor Christopher P. Evans, MD, FACS

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