What are the recommended screening guidelines and treatment options for prostate health?

Prostate Cancer Screening Guidelines

For men aged 55-69 years, engage in shared decision-making about PSA screening, but do not implement population-based screening programs; for men over 70 years or with life expectancy under 10 years, do not screen. 1

Screening Recommendations by Age and Risk

Average-Risk Men (Age 50-69)

• Begin discussions about PSA screening at age 50 for average-risk men with life expectancy ≥10 years 1
• The European screening trial demonstrated a 21% relative reduction in prostate cancer mortality (29% adjusted for non-compliance) after 13 years, but 781 men needed screening and 27 needed treatment to prevent one death 1
• PSA screening combined with digital rectal examination (DRE) should be offered annually if the patient chooses screening after informed discussion 1

High-Risk Men

• African American men and those with first-degree relatives diagnosed before age 65 should begin screening discussions at age 45 1
• Men with multiple close relatives diagnosed at early ages should begin discussions at age 40 1
• Black men have significantly higher incidence rates (173.0 per 100,000) compared to White men (97.1 per 100,000) 2

Men Over 70 Years

• Do not screen asymptomatic men over age 70 or those with life expectancy <10 years 1
• The average 75-year-old has approximately 10 years life expectancy, and mortality benefit requires >10 years to manifest 1

Screening Tests and Thresholds

PSA Testing

• Use PSA threshold of 4.0 ng/mL as the conventional cutoff for further evaluation 3
• A single elevated PSA should not prompt immediate biopsy; verify with a second value 1
• For men with PSA <1.0 ng/mL at age 60, repeat testing in 2-4 years 4
• PSA has 70% sensitivity for prostate cancer detection with 20-25% false-negative rate and 65% false-positive rate 3

Digital Rectal Examination

• PSA detects significantly more cancers (82%) than DRE alone (55%) 5
• Any abnormality on DRE suggestive of cancer should prompt ultrasound-guided biopsy even with normal PSA 4
• The combination of PSA and DRE increases cancer detection rate to 5.8% versus 4.6% for PSA alone or 3.2% for DRE alone 5

Screening Intervals

• Annual screening is not supported by evidence; screening every 4 years may provide similar mortality benefit 1
• The European trial screened most patients every 4 years (range 2-7 years) and demonstrated mortality reduction 1

Diagnostic Workup

When to Biopsy

• Perform transrectal ultrasound-guided biopsy with antibiotic prophylaxis and local anesthesia, obtaining minimum 10-12 cores 1
• Indications for biopsy include: PSA >4.0 ng/mL, suspicious DRE, abnormal multiparametric MRI, or rising PSA 1
• Before repeat biopsy, obtain multiparametric MRI for MRI-guided or MRI-TRUS fusion biopsy 1

Advanced Diagnostics

• Multiparametric MRI is recommended before biopsy in patients with elevated PSA or risk factors, but not indicated for low-risk patients (low PSA and normal DRE) 4, 6
• Free-to-total PSA ratio <25% increases cancer suspicion; normal ratio is ≥22% 4
• PSA velocity >0.35-0.75 ng/mL/year may predict malignancy 3

Staging for Diagnosed Cancer

Risk-Based Staging

• Patients with intermediate- or high-risk disease require staging with technetium bone scan and thoraco-abdominal CT or whole-body MRI or choline PET/CT 1
• Patients unsuitable for curative treatment due to poor health do not require staging investigations 1

Treatment Options by Risk Category

Low-Risk Localized Disease

• Active surveillance is appropriate for one-third of patients with localized prostate cancer and well-informed patients with low-risk disease 2
• Active surveillance involves serial PSA measurements, prostate biopsies, or MRI with treatment initiation if Gleason score or stage increases 2
• Approximately 75% of patients present with localized disease, associated with nearly 100% 5-year survival 2

Higher-Risk Localized Disease

• Radical prostatectomy or radiation therapy are reasonable options for higher-risk disease 2
• Treatment decisions should incorporate adverse events and comorbidities 2
• 71% of radical prostatectomy patients had organ-confined cancer, with PSA detecting 75% versus DRE detecting 56% 5

Advanced/Metastatic Disease

• Androgen deprivation therapy is first-line for metastatic prostate cancer, typically using gonadotropin-releasing hormone agonists 2
• Adding androgen receptor pathway inhibitors (abiraterone, darolutamide) improves median overall survival from 36.5 to 53.3 months (HR 0.66) 2
• Chemotherapy with docetaxel should be considered for extensive disease 2
• Approximately 10% present with distant metastases, associated with 37% 5-year survival 2

Critical Shared Decision-Making Elements

Information to Discuss

• Inform patients that PSA screening reduces prostate cancer mortality at the expense of overdiagnosis and overtreatment 1
• 80% false-positive rate when PSA cutoff is 2.5-4.0 ng/mL 1
• Treatment harms include 11% increased urinary incontinence risk and 37% increased erectile dysfunction risk with radical prostatectomy 1
• Sexual dysfunction, infertility, bowel and urinary problems are potential treatment complications 1

Common Pitfalls

• Do not order PSA without first discussing potential benefits and harms 1
• Avoid prostate biopsy based solely on abnormal transrectal ultrasound; nearly 40% of tumors would be missed using this criterion alone 5
• Remember that 5α-reductase inhibitors reduce PSA by approximately 50% within 6 months; double PSA values for comparison 3
• Avoid vigorous exercise and ejaculation for 2 days before PSA testing to prevent false elevations 3