What is the standard of care for Prostate-Specific Antigen (PSA) testing?

From the Guidelines

The standard of care for PSA testing involves shared decision-making between patients and healthcare providers, with men aged 55-69 discussing the potential benefits and harms of PSA screening with their doctor, as this age group may benefit most from testing. The decision to screen for prostate cancer using the prostate-specific antigen test should be based on the risk for prostate cancer, a discussion of the benefits and harms of screening, the patient's general health and life expectancy, and patient preferences 1.

Key Considerations

• Men under 50 or over 69 years old, or those with a life expectancy of less than 10-15 years, should not be screened for prostate cancer using the PSA test, as the harms of screening outweigh the benefits in these groups 1.
• African American men and those with a family history of prostate cancer should consider starting discussions about screening earlier, around age 40-45, due to their higher risk 1.
• The PSA test itself is a simple blood test that measures a protein produced by prostate cells, and a level above 4.0 ng/mL is generally considered elevated, though this threshold may vary based on age, race, and other factors 1.
• The rationale for selective screening is that while PSA testing can detect prostate cancer early, it may lead to overdiagnosis and overtreatment of slow-growing cancers that might never cause symptoms, resulting in unnecessary anxiety and treatment complications 1.

Screening Frequency

• There is no clear evidence to guide decisions about the frequency of PSA screening, but increasing the interval between screening tests may reduce harms 1.
• The ERSPC trial, which screened men every 4 years, found a reduction in prostate cancer mortality, suggesting that longer intervals may be indicated 1.

Shared Decision-Making

• Clinicians should not screen for prostate cancer in men who do not wish to make the screening decision or do not express a clear preference about screening 1.
• Shared decision-making is important in making choices about prostate cancer screening, and clinicians should elicit patient preferences for screening and discuss the benefits and harms of screening 1.

From the Research

Standard of Care for PSA Testing

• The US Preventive Services Task Force (USPSTF) recommends that men aged 55 to 69 years discuss the potential benefits and harms of prostate-specific antigen (PSA)-based screening for prostate cancer with their clinician 2.
• The decision to undergo periodic PSA-based screening should be an individual one, taking into account factors such as family history, race/ethnicity, comorbid medical conditions, and patient values 2.
• For men aged 55 to 69 years, the USPSTF concludes with moderate certainty that the net benefit of PSA-based screening is small, and that the potential benefits of screening do not outweigh the expected harms for men 70 years and older 2.
• The USPSTF recommends against PSA-based screening for prostate cancer in men 70 years and older 2.

Benefits and Harms of PSA Testing

• PSA-based screening programs may prevent approximately 1.3 deaths from prostate cancer over approximately 13 years per 1000 men screened, and may also prevent approximately 3 cases of metastatic prostate cancer per 1000 men screened 2.
• However, screening programs may also result in frequent false-positive results and psychological harms, as well as harms from treatment, including erectile dysfunction, urinary incontinence, and bowel symptoms 2.
• The harms of screening in men older than 70 years are at least moderate and greater than in younger men, due to increased risk of false-positive results, diagnostic harms from biopsies, and harms from treatment 2.

High-Risk Populations

• Men with a family history of prostate cancer or who are of African American descent may benefit from earlier or more frequent screening 3.
• The use of percent free PSA may be useful in detecting early-stage but clinically significant cancers in men with a total PSA value between 2 and 4 ng/mL and normal digital rectal examination findings 3.

Digital Rectal Examination

• Digital rectal examination may be useful in detecting prostate cancer in men with suspicious findings and serum PSA levels of 4 ng/mL or less 4.
• The positive predictive value of a suspicious digital rectal examination is appreciable in men with low serum PSA levels, and the majority of cancer cases detected by digital rectal examination have features of clinically important and potentially curable disease 4.