What are the guidelines for Prostate-Specific Antigen (PSA) screening?

From the Guidelines

Prostate-specific antigen (PSA) screening for prostate cancer should be discussed with men aged 55-69, as this is the group most likely to benefit, according to the most recent and highest quality study 1. The decision to screen should be individualized based on personal preferences and risk factors. For men who choose screening, testing should occur every 2-4 years rather than annually. The screening process involves a blood test measuring PSA levels, with values above 4.0 ng/mL generally warranting further evaluation. Some key points to consider when discussing PSA screening with patients include:

• Men with risk factors such as African American race or family history of prostate cancer should begin discussions about screening earlier, around age 40-45 1.
• Screening is not recommended for men under 40 or those with less than 10-15 years life expectancy 1.
• The benefit of PSA screening is early detection of prostate cancer, potentially reducing mortality, while drawbacks include false positives leading to unnecessary biopsies and potential overdiagnosis of indolent cancers that might never cause harm.
• A shared decision-making approach is essential, taking into account the patient's values, preferences, and individual risk factors 1.
• The American College of Physicians recommends that clinicians inform men between the ages of 50 and 69 about the limited potential benefits and substantial harms of screening for prostate cancer, and base the decision to screen 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. This balanced approach aims to maximize benefits while minimizing harms from overdiagnosis and overtreatment.

From the Research

PSA Screening Guidelines

• 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 USPSTF concludes that the net benefit of PSA-based screening for prostate cancer in men aged 55 to 69 years is small, and that the decision to undergo screening should be an individual one 2.
• For men aged 70 years and older, the USPSTF recommends against PSA-based screening for prostate cancer, as the potential benefits do not outweigh the expected harms 2.
• A study published in The New England Journal of Medicine found that screening for prostate cancer with magnetic resonance imaging (MRI) and PSA can reduce the detection of clinically insignificant prostate cancer 3.
• Another study published in Diagnostic and Interventional Imaging found that biparametric MRI (bpMRI) combined with PSA density can improve the diagnostic accuracy for clinically significant prostate cancer in patients with PSA serum levels of 4-10 ng/mL 4.
• A study published in BJU International found that the percentage of PSA isoform [-2]proPSA and the Prostate Health Index can improve the diagnostic accuracy for clinically relevant prostate cancer at initial and repeat biopsy compared with total PSA and percentage free PSA in men aged ≤65 years 5.
• A study published in Urology found that free PSA can improve prostate cancer detection in a high-risk population of men with a normal total PSA and digital rectal examination 6.

Benefits and Harms of PSA Screening

• The benefits of PSA screening include the potential to prevent approximately 1.3 deaths from prostate cancer over approximately 13 years per 1000 men screened, and to prevent approximately 3 cases of metastatic prostate cancer per 1000 men screened 2.
• The harms of PSA screening include frequent false-positive results, psychological harms, and the potential for overdiagnosis and overtreatment 2.
• The harms of prostate cancer treatment include erectile dysfunction, urinary incontinence, and bowel symptoms, with approximately 1 in 5 men who undergo radical prostatectomy developing long-term urinary incontinence, and 2 in 3 men experiencing long-term erectile dysfunction 2.

Screening Strategies

• The USPSTF recommends that clinicians discuss the potential benefits and harms of PSA screening with their patients, and that the decision to undergo screening should be an individual one 2.
• A study published in The New England Journal of Medicine found that screening for prostate cancer with MRI and PSA can reduce the detection of clinically insignificant prostate cancer, and that omitting biopsy in patients with negative MRI results can eliminate more than half of diagnoses of clinically insignificant prostate cancer 3.
• Another study published in Diagnostic and Interventional Imaging found that bpMRI combined with PSA density can improve the diagnostic accuracy for clinically significant prostate cancer in patients with PSA serum levels of 4-10 ng/mL, and that bpMRI has a higher specificity than multiparametric MRI (mpMRI) 4.