Prostate-specific antigen (PSA) testing for prostate cancer screening should proceed only after careful discussion of risks and harms with patients, and should target men ages 55 to 69, according to the American Urological Association’s first-ever clinical guideline on the topic.
In a major departure from previous statements, the AUA recommends no routine screening of average-risk men 40 to 54. The AUA does not recommend routine screening after age 70 or for any men who have a life expectancy less than 10 to 15 years.
The AUA recommends against screening PSA tests for men younger than 40.
“This guideline is a more targeted approach to PSA screening, directing our efforts in terms of PSA screening toward those who are most likely to benefit from screening, and that is the age group where there is the most evidence for benefit, the age group between 55 and 69,” said H. Ballentine Carter, MD, of Johns Hopkins Hospital, who chaired the panel that developed the guideline.
“We’re not saying people outside that age range couldn’t benefit or that there aren’t some men who might benefit,” he added, emphasizing that the recommendation pertains to average-risk men.
The guideline will be discussed in detail at a press briefing later today, prior to the start of the AUA meeting here.
Prostate-specific antigen (PSA) testing for prostate cancer screening should proceed only after careful discussion of risks and harms with patients, and should target men ages 55 to 69, according to a new American Urological Association guideline.
Point out that in a major departure from previous statements, the AUA recommends no routine screening of average-risk men 40 to 54.
The AUA issued a practice statement on PSA testing in 2009, but had not previously developed a clinical guideline on the issue. The practice statement addressed early detection but also covered risk stratification and prostate cancer management, Carter said.
Prostate-Specific Antigen (PSA) Blood Test
Prostate-specific antigen (PSA) is a substance produced by the prostate gland. Elevated PSA levels may indicate prostate cancer, a noncancerous condition such as prostatitis, or an enlarged prostate.
Most men have PSA levels under four (ng/mL) and this has traditionally been used as the cutoff for concern about the risk of prostate cancer. Men with prostate cancer often have PSA levels higher than four, although cancer is a possibility at any PSA level. According to published reports, men who have a prostate gland that feels normal on examination and a PSA less than four have a 15% chance of having prostate cancer. Those with a PSA between four and 10 have a 25% chance of having prostate cancer and if the PSA is higher than 10, the risk increases to 67%.
In the past, most experts viewed PSA levels less than 4 ng/mL as normal. Due to the findings from more recent studies, some recommend lowering the cutoff levels that determine if a PSA value is normal or elevated. Some researchers encourage using less than 2.5 or 3 ng/mL as a cutoff for normal values, particularly in younger patients. Younger patients tend to have smaller prostates and lower PSA values, so any elevation of the PSA in younger men above 2.5 ng/mL is a cause for concern.
Just as important as the PSA number is the trend of that number (whether it is going up, how quickly, and over what period of time). It is important to understand that the PSA test is not perfect. Most men with elevated PSA levels have noncancerous prostate enlargement, which is a normal part of aging. Conversely, low levels of PSA in the bloodstream do not rule out the possibility of prostate cancer. However, most cases of early prostate cancer are found by a PSA blood test.
Much of the practice statement was based on consensus and expert opinion, he added. The guideline evolved from the findings of an independent group commissioned by the AUA to perform a comprehensive review of the evidence, following recommendations from the Institute of Medicine.
Should I have the PSA test?
The limitations of PSA testing
- It can miss cancer and provide false reassurance.
- It may lead to unnecessary worry and medical tests when there is no cancer.
- It cannot tell the difference between slow-growing and fast-growing cancer.
- It may make you worry by finding slow-growing cancers that may never cause any symptoms or shorten your life.
- 48 men will undergo treatment in order to save one life.
The benefits of PSA testing
- It may reassure you if the test result is normal.
- It may give you an indication of cancer before symptoms develop.
- It may find cancer at an early stage when treatments could be of benefit.
- If treatment is successful, the worst possible outcomes of more advanced cancer, including death, are avoided.
- Even if the cancer is more advanced and treatment is less successful, it will usually extend life.
The review covered relevant literature published from 1995 to 2013. The AUA guideline panel considered the quality of evidence supporting PSA testing in four age-defined index patient groups:
<40, 40 to 54, 55 to 69, and ≥70.
The guideline panel limited their focus to the efficacy of PSA screening for early prostate cancer diagnosis with the specific intent of reducing prostate cancer mortality. Use of secondary tests to inform on the need for prostate biopsy or repeat biopsy was not considered.