Tag Archives: psa testing

January 22, 2022 · 6:23 pm

Keeping up…(or not)


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In my book club (all old men from various backgrounds – medicine, law, business, politics, academia, etc.) we read a book called “Artificial Intelligence: Confronting the Revolution“. In it, the author describes the various scenarios underway to deal with massive amounts of information. Far beyond Deep Blue, the chess computer that beat Kasparov in 1997, AI may help physicians of the future make great diagnoses and decisions and is already being tested in difficult settings like the early detection of pancreatic cancer.

Until then, for me at least, drowning in the information for oncology in general, and even just for prostate cancer is becoming daunting. Gone are the days when reading the New England Journal of Medicine would keep you abreast of the most important advances. This is a photograph of the journals that arrived just this week, all provided for “free” (and without my request) by the endless advertising in the first pages.

In “GU Oncology Now” there is a summary of important papers presented at the Society of Urologic Oncology 2021. For prostate cancer two papers on PSMA imaging and therapy (which I have covered elsewhere), one on racial differences and treatment patterns, and an ad for “why is precision medicine complicated in advanced prostate cancer?” (See the answer here) Hematology and Oncology covers “highlights from the 2021 European Society for Medical Oncology Congress and the 2021 AUA Meeting”. That one has 4 articles on darolutamide, 3 on enzalutamide, 2 on PD-1 inhibitor trials, and “meeting abstract summaries with expert commentary”. Scanning them, I find that for the most part I have already commented on many of them in this blog, so I move on to: This week’s NEJM. There, in looking at the table of contents, I find articles on diabetes control using “closed loop” glucose monitoring and insulin administration, use of oral microbiome therapy for c. diff infections, antibiotic prophylaxis for rheumatic heart disease, and one on 24 hour urinary sodium excretion and cardiovascular risk. Whew…nothing on prostate cancer –but wait, there IS one on an antibody drug conjugate for treating lung cancer…I wonder if it could have any role in the small number of prostate cancers that also have HER-2 mutations??

Oh, well, let’s move on… The Lancet Oncology has 12 original articles, 11 commentaries and 6 letters to the editor, and there are a couple of the letters that deal with prostate cancer from researchers I know personally. But wait – they are available online at “e7” and deal with “radiographic progression-free survival in the ACIS trial”. I already know about that since I was a monitor for that trial, so guess I’ll pass. That leaves JAMA Oncology. OMG! The first three articles I really do have to read. Here it goes:

  1. “Changes in Prostate-Specific Antigen Testing Relative to the Revised US Preventive Services Task Force Recommendation on Prostate Screening” This turns out to be an analysis of Blue Cross Blue Shield beneficiaries (some 8 million or so) aged 40-89 between 2013 and 2019. During that time, the USPSTF changed its guidelines from “not indicated” to “shared decision” and sure enough, PSA testing increased 10% among men 40-54 years old, 12% in those 55-69 years old, and 16% in the group least likely to benefit, aged 70 to 89. Hmmm.
  2. “Association of Treatment Modality, Functional Outcomes, and Baseline Characteristics With Treatment -Related Regret Among Men with Localized Prostate Cancer” Wow – I talk to men about treatment decisions like this almost every week. This one looked at 2072 men with localized prostate cancer diagnosed in 2011 and 2012, then analyzed in late 2020/early 2021, so almost 10 years of followup. The number of interesting observations in the 3 tables and 2 figures found in the article are too numerous to go over in this blog, but among them are more treatment regret among patients who received surgery or radiation vs those who chose active surveillance, less treatment regret in college or more graduates, and as expected more regret in men who had health problems related to treatment. But the concluding paragraph says it all:
    “The findings of this cohort study suggest that more than 1 in every 10 patients with localized prostate cancer experience treatment-related regret. A disconnect between patient expectations and outcomes, both as it relates to treatment efficacy and adverse effects, appears to drive treatment-related regret to a greater extent than factors including disease characteristics, treatment modality, and patient-reported functional outcomes such as urinary incontinence and other urinary symptoms, erectile dysfunction, or bowel dysfunction. Thus, improved counseling at the time of diagnosis and before treatment, including identification of patient values and priorities, may decrease regret among these patients.” I guess this validates the way I often end up my own counseling sessions: “Unfortunately, Mr. (and Mrs. in some cases) XYZ, there just isn’t any way to treat the prostate gland without causing some side effects.”
  3. “Outcomes of Screening for Prostate Cancer Among Men Who Use Statins”. This one is from Finland where we spent a lovely year on sabbatical in the mid-1980’s. My wife studied the Finns’ vaccination data for childhood meningitis, and I did a year in a molecular biology lab. We both were impressed with the Finnish Public Health system. The article utilized that system’s extensive database to evaluate the effect of statin use among 78,606 men who were part of a randomized study to evaluate PSA screening effects. The incidence of low grade (Gleason 6) cancers was reduced among the statin users, whereas detection of high risk cancers (Gleason 8-10) was similar. Buried in the data (3 figures, 2 tables) is a nugget. There is a trend towards decreased risk for all kinds of prostate cancer among statin “ever” users vs. non-users although no difference in mortality. Still…the study seems to support my bias that if tolerated (~5-10% of patients on statins develop muscle inflammation) most of my patients might benefit from being on statins.

Well, that’s it for this week’s journal arrivals. I won’t bother you with the 5-10 emails I scan every day from all sorts of “Web MD” and “Grand Rounds in Urology” places with even more to try and digest. How anybody can be a general medical oncologist these days and care for everything from lymphoma to breast cancer is truly amazing. Fortunately, there are expert resources like the NCCN Guidelines that are really helpful. Goodness knows we need them, and maybe AI will save us, but I’m not so sure.

Take a look, for example, at just the number of articles published so far in 2022 on statins and prostate cancer. Good luck 😁.

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September 26, 2021 · 10:26 pm

The Future of [Prostate] Cancer Screening


As I’m sure most of you know, this has been a controversial topic for more than 2 decades. The problem is fairly simple: Screening can pick up earlier disease, save some lives, but treatment has side effects for virtually 100% of men who get treated, and “active surveillance” is not a picnic with repeat biopsies every 2-3 years. We may have to treat as many as ten men to save one life. On the other hand, if they live long enough, more than half of men probably develop prostate cancer, usually of the low grade (Gleason 6 or less) type that will never bother them. Here is a nice article that shows how autopsy series over time have found prostate cancer in up to half of men, dependent on age, race, etc. but notably pointing out how seldom autopsies are now performed compared to earlier eras. The reality is that we have no idea these days how many 90 year old men would have a small cancer if we really looked hard for it. What we understand is that they didn’t need to know they had a prostate cancer if they were never treated and died from something else.

Now, add to these challenges the revolution in cancer detection provided by molecular testing. This field is moving so fast that the “old idea” of PSA screening is becoming passé. For example, Illumina, the company that makes automated next generation sequencing machines spun off a startup, GRAIL that developed a “pan-cancer” test that looks for fragments of DNA circulating in the blood, the fingerprints for most of the common cancers. This test, called “Galleri” is undergoing real world testing in the UK, but is not covered or approved in the U.S. Proponents (some of whom are consultants for biotech companies) suggest that it could save “millions of lives”. The test, because we live in a free, capitalistic society is already marketed on the internet for an out-of-pocket price of only $949 with payment plans available. But…and the prostate cancer community knows this perhaps better than any other…the challenge of knowing whom to test, when to test, and what to do with a positive test may take decades to figure out. Here’s an article covering some of those promises and challenges (false positives, lead time bias, costs for treatment, etc.)

But for prostate cancer, the same DNA technology is making real progress. What we want are tests that not only tell us who has prostate cancer, but who has the kind of cancer that NEEDS to be treated or followed closely, and lowers the detection of clinically insignificant cancers. An example of this kind of testing sophistication appeared in NEJM this month from a group in Stockholm. This group has developed a test called Stockholm3 that is “a risk-prediction model that is based on clinical variables (age, first-degree family history of prostate cancer, and previous biopsy), blood biomarkers (total PSA, free PSA, ratio of free PSA to total PSA, human kallikrein 2, macrophage inhibitory cytokine-1, and MSMB), and a polygenic risk score (a genetic score based on 254 single-nucleotide polymorphisms [SNPs] and an explicit variable for the HOXB13 SNP) for predicting the risk of prostate cancer with a Gleason score of 7 or higher.” They then took men at risk of having prostate cancer (PSA>3 and Stockholm3 >11%) and either did “blind” 12 core biopsies or did an MRI first and included targeted biopsies of high risk lesions only if seen on the MRI.

Outcome for Stockholm3 high risk screened men with PSA > 3 who did or did not have MRI targeted biopsy in addition or instead of standard biopsy.

Note that the number of biopsies needed went down, as did the number of benign or clinically insignificant cancers. This is the sort of effort that will eventually reduce the number of men having unnecessary biopsies or treatment by combining all of the great new molecular and radiology technologies (dynamic contrast enhanced MRI’s). We now routinely use some of the molecular tests to help us in screening and deciding about treatments as I reviewed in this blog.

While we are still a long way from applying this kind of technology to “every man over 50”, the future for the next generation (our sons and grandsons) will be much better – fewer unnecessary biopsies and treatments. Hopefully this type of approach can be applied to the pan-cancer type of “Galleri” screening being proposed, and make such testing cost effective as well. Congratulations to the prostate cancer researchers and their patients for leading the way!

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January 22, 2020 · 3:59 am

Dear Abby, my PSA…


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If you are a reader of this blog, it is likely that you or a close friend/relative has dealt with or are dealing with prostate cancer. Hence, you have become the “expert” in your family or book club or similar for people who know your story. One of the most frequent questions I encounter in such circumstances is a question about someone’s recent PSA. As an example, an 86 year old otherwise healthy cardiologist recently called me asking what to do about his  PSA that had gone from 4-ish to 6-ish during the last 2 years.

There are a few generalizations that seem to apply to most of these queries. First, the PSA increases at a fairly predictable rate with age. As a crude rule of thumb, I tell patients/friends that it should be less than 2 when you are 50, less than 3 when you are 60, and less than 4 when you are 70. A recent article in JAMA illustrates this point nicely. In the PLCO cancer screening trial, 10,968 men aged 55-60 had a baseline PSA drawn and were then followed with various screening strategies for prostate, colon, or lung cancer. Among the men with baseline PSA of <0.99, the incidence of developing clinically significant prostate cancer in the next 13 years was only 1.5%, whereas if their baseline PSA was 2-2.99, the chances increased to 10.6%. The authors concluded that ” These findings suggest that repeated screening can be less frequent among men aged 55 to 60 years with a low baseline PSA level (ie, <2.00 ng/mL) and possibly discontinued among those with baseline PSA levels of less than 1.00 ng/mL.” What to do for my octogenarian cardiologist friend is more complicated, of course.

A second generalization is that if someone has chosen to follow his PSA more closely, say on an annual basis, because they have read enough about screening to feel that regardless of the controversy, they wish to do so, they should plot their data. A column of numbers is much harder to interpret than a visual graph. There is an easy way to do this by entering the data on a website like this one: Doubling-Time.  It is also important to realize that different labs may give slightly different values on the same patient – particularly challenging if one is trying to torture the data in the lowest ranges of detectability (<0.2).

Thirdly, and related to the plotting approach, for any given patient with known metastatic prostate cancer, the absolute value of PSA may be less important than the rate of change (doubling time). A rising PSA that goes from 3 to 6 in 6 months is of greater concern than someone with a PSA going from 150 to 160. Of course having a lower value generally means a lower cancer burden, but I once had a patient enjoy elk hunting during the later stages of his disease with a PSA over 2000. He had relatively few symptoms in spite of his advanced disease.

Lastly, and related to my aging cardiologist friend, there’s a lot more to know than the PSA in most cases. When I asked him what his urinary habits were (unchanged) and what his rectal exam revealed (he hadn’t had one), I suggested he should visit a urologist for a more complete picture. If you biopsied his prostate, there is probably >50% chance of finding cancer at his age, but the key question is whether it would be a “clinically significant” cancer (Gleason score >3+3=6, or multiple cores positive etc.) In addition, one now has the opportunity to do pre-biopsy tests such as Select MDx, PHI, or ExoDx with newer tests being developed all the time to try and NOT find patients with low risk disease who might never need any sort of treatment.

So, at your next cocktail party when a friend asks about PSA, you can gently explain the complexities you are all too familiar with, and hopefully guide them in the right direction. And if you are interested in more blogs, I recently discovered Snuffy Myers’ blog site, Prostapedia, that has numerous blogs from highly respected prostate experts with great ongoing updates. Happy New Year and most importantly EXERCISE!

 

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February 25, 2016 · 11:28 am

No pain, no gain?


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One of my patients last week had a heartfelt discussion regarding the survival benefit of ADT vs his quality of life. He enjoys body building and showed me some pretty dramatic pictures of himself during his last ADT cycle (on intermittent therapy) versus now, when he had been off treatment for ~6-9 months. Added to his concern was his decline in libido and sexual function during ADT, a common complaint especially among younger patients. The question of quality vs quantity of life was,of course, utmost on his mind.

Starting from the initial diagnosis, every (maybe that should be every !!) prostate cancer patient will experience a decrement in quality of life. Those who elect “watchful waiting” will nevertheless experience anxiety regarding the shadow of CANCER following their footsteps. Sure, you can put it out of your mind, but turn around and there it is, like the neighbor’s unwanted cat stalking you. Then there is the anxiety over what the next PSA will be. And if on active surveillance, what will that next biopsy show?? These issues are both real, disturbing, and often under-appreciated in the discussions surrounding screening…”we should still be screening, but not treat the men who don’t need it…” Really? What about the 80% of men who die at age 90 with prostate cancer at autopsy who never had to deal with the shadow? (The inevitable counter-argument is, “yes, and what about those who had early detection of a high grade cancer whose life was saved?”)

We also tend to ignore the impact of competing mortality in our discussions. “Sure you had a stent placed last year, and you already survived that small colon cancer, so why wouldn’t we be aggressive in treating this new problem?” Dr. Sartor provided an elegant discussion of this in an editorial on the PIVOT trial you can read here. Whatever the flaws in that study, it remains clear that we are not very good at predicting the non-prostate cancer “future” for our patients, and the older you are, the thinner the ice gets regardless of how many marathons you run.

When patients choose one form of primary treatment vs another, they are weighing the different side effect profiles of surgery or radiation as much as which is “most effective”. I often give patients a copy of this article from NEJM and encourage them to spend some time looking at the graphics in Figure 1 to get some idea of what they will face in the way of side effects from treatment. As any honest physician would tell them, treatment will involve side effects, some permanent, in the best of circumstances.

In the setting of more advanced disease, for example a patient who presents with metastases outside the pelvis, the recent CHAARTED and STAMPEDE trials both suggest an advantage to the earlier use of docetaxel chemotherapy in combination with ADT as opposed to ADT alone. These data suggest that “pay me now or pay me later” analysis favors the “pay me now” approach in terms of overall survival. But at what price for quality of life? Fortunately most chemotherapy side effects are reversible, but distinctly unpleasant, potentially making the equation something like “4 months of misery to provide 14 months of longer life….not all of which will be great anyway”.

Even in the very advanced setting, there is some evidence that greater toxicity results in improved survival. A recent analysis of the TROPIC trial of cabazitaxel suggested that the patients who had the most “toxic response” in terms of dropping their neutrophil count benefited the most in terms of overall survival.

While all of this seems incredibly negative (for which I apologize), the history of oncology as a field has been the incremental improvement in survival AND the development of newer treatments that provide such advances with diminishing toxicity. Pediatric leukemia, as discussed extensively in “The Emperor of All Maladies” is a great example of how pioneering patients and physicians worked together to find cures and reduce side effects. We may only be at the beginning of such achievement in prostate cancer, but with the advent of the newer hormonal and imaging agents, increasingly sophisticated surgery and radiation, vaccines and immunotherapy, and even the chemotherapies now available, we have  no doubt reached the end of the beginning. Onward!

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October 30, 2014 · 10:39 am

Yay…Movember is here. Let’s kick Pca


Hi friends and relatives (those who will admit it…),

This Movember, I’ve committed my upper lip to help change the face of men’s health by growing a moustache, now I need your support at http://mobro.co/michaelglode.The Movember Foundation is the leading global organization committed to changing the face of men’s health. I’m passionate about this cause because too many men are dying unnecessarily from prostate cancer. In 2014, more than 233,000 men will be diagnosed with prostate cancer. Even better, join our team and donate to yourself and invite your friends/family to the cause! Our team is here: http://us.movember.com/mospace/index/search/?q=university%20colorado

 The Movember Foundation is working tirelessly with an urgent goal in mind: accelerating breakthroughs in prostate cancer research that will benefit patients and their families. Movember is achieving this with the formation of the largest, global alliance of prostate cancer researchers and clinical specialists, who are tackling the toughest prostate cancer challenges. I had the privilege of hearing the updates on the research they have been sponsoring last week at the PCF retreat. More progress in the last 5 years than in the previous 25. Take a look there for updates/posts yourself!

I need your support to fund this important work. Together, we can create a world where no man dies of prostate cancer.

You can donate by:

– Donating online at http://mobro.co/michaelglode (and follow the pathetic growth of my not-so-manly moustache…)

– Writing a check to ‘Movember’, referencing my registration ID: 5798901 and mailing it to:  Movember, P.O. Box 1595, Culver City, CA 90232

You can learn more about the important work and impact Movember is having at: http://us.movember.com/programs. There’s a lot riding on this moustache, thank you for your support!

 Mo Bro Michael Glode

http://mobro.co/michaelglode

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May 15, 2014 · 2:06 pm

Oh, no! My PSA is going up….do something….


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One of the most frustrating and frightening things that can happen to a prostate cancer patient is for there to be a recurrence of the PSA after he thought he had been cured by surgery, radiation therapy, or both. This is entirely understandable. It is no picnic to go through those treatments in the first place, and when the PSA is clearly going up, it can only mean (with very rare exception) that there are still cancer cells lurking somewhere in the body. The rate of the PSA rise can predict how long it will be until something shows up on a scan, and on average, this is about EIGHT years. The median time to death from prostate cancer after a PSA recurrence is 16 years.

For >95% of patients there is something that CAN be done to stem the rise in PSA. That is to go on hormonal therapy (androgen deprivation, ADT) which will drop the PSA, often all the way to undetectable levels, in over 95% of patients. Voila! Both patient and physician feel much better emotionally. But for the patient, there is a significant price to pay. Namely the hot flashes, loss of energy, weight gain, bone calcium loss, lack of libido and further decrease in sexual function to name a few. The question is whether this is “worth it”.

A study to be presented in the next few weeks at ASCO’s annual meeting, suggests it won’t make much difference if you start ADT early versus waiting until metastases, or perhaps even symptoms occur. Utilizing the CaPSURE database, the investigators evaluated over 2000 men who had PSA relapse. The estimated 5 year overall survival (87% vs 85%) and 10 year overall survival (72% vs 72%) were the same regardless of whether the men received immediate or delayed ADT. The same was true for death from prostate cancer…no significant difference. There are of course other considerations that may come into play like treating those patients who have highly aggressive disease earlier because one knows that there will be metastases within a year, or the patient simply can’t live with himself knowing his PSA is going up.

In my experience, it is the exceptional patient who is willing to go play golf or travel or enjoy his grandchildren and forgo PSA testing on a regular basis. I have trouble even convincing my patients to extend their PSA testing to 6 months from 3 months. The question is, does it make any sense to watch this “number”, any more than it would to have cardiac catheterization every 3 months to follow the slow but inexorable accumulation of calcium in your coronary artery? Or what about the 0.01 mm increase in your abdominal aortic aneurysm? Or the accumulation of two more tangles in the Alzheimer plaque in your brain. Just because we CAN measure PSA so easily certainly doesn’t mean we SHOULD, and I have seen far too many men let this number ruin their otherwise healthy lives.

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March 22, 2014 · 10:28 am

No surgery or radiation. Just make my PSA go down!


To read this blog on the website and have access to subscribing and older posts click here. What if you could avoid all of the well-known side effects of surgery or radiation and just take hormone therapy? (aka Androgen Deprivation Therapy or ADT) Given the incredible power of the PSA value to drive thinking of both physicians and patients, this question makes a lot of sense. >95% of patients will have a PSA response to ADT, usually in the form of GnRH agonists (e.g. Lupron, Zoladex, Trelstar, etc) or antagonists (Firmagon, Plenaxis) You might imagine that dropping the PSA would be all that is needed in some men and if they didn’t have too many side effects (weight gain, hot flashes, muscle weakness) they would benefit from the treatment.

A study just reported looked at 3435 men treated in this way between 1995 and 2008 to determine if such treatment would reduce death from prostate cancer and compared them to 11735 men who did not receive such treatment. The age ranged from 35 to >80 and as you might suspect, there was a statistically significant tendency to use treatment in older individuals, in men with higher PSA at diagnosis, and in those with higher Gleason scores. Anyone who received radiation or surgery within the first year after treatment was excluded from the analysis. The bottom line is that there was no effect of using such treatment. To quote the authors, “Our main conclusion is that PADT does not seem to be an effective strategy as an alternative to no therapy among men diagnosed with clinically localized PCa who are not receiving curative-intent therapy. The risks of serious adverse events and the high costs associated with its use mitigate against any clinical or policy rationale for PADT use in these men.”

This study adds to the complexities surrounding prostate cancer diagnosis and treatment. Screening and treating patients with surgery or radiation after age 65 may not produce any positive results in the large screening studies, or at the least, you have to treat a significant number of men who would not need treatment to save one life. While you can make the PSA go down with ADT, it also does not save any lives. Such is the challenge of whom to diagnose, whom to treat, and how to best treat anyone who you think does need treatment. On this blog you will find many entries on these issues, and as I have stated before, when you ask men who are dealing with the disease, they virtually all think their treatment either saved their life or was given too late – illustrating the difference between a population and an individual view. The silver lining is that whether you are diagnosed with pca before you die or not, regardless of treatment choice, you are more likely to die from something else.

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August 23, 2013 · 9:52 am

Shift work and PSA values


I just came across this article because the editors at Medscape send around interesting articles on prostate cancer when you sign up for them. It seems likely to me that this is not a red herring, but the accompanying editorial goes into the issues of more holistic prostate cancer screening – with the intent to try and figure out who might really benefit rather than just screening all men over age 50. If you could reduce the denominator in some way by eliminating men who have the “usual, non-threatening” “cancer” (with a nod to all the articles suggesting we should change the nomenclature for Gleason 3+3 disease), screening might make more sense and be of greater benefit. Until then, it’s still caveat emptor.

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August 15, 2013 · 10:26 pm

PCPT rides again – finasteride (proscar) to the rescue?


Today’s NEJM has a great article written by our colleagues who headed this study designed to ask whether taking finasteride could reduce the incidence/death rate of prostate cancer. This is the same group that reported on fish oil being a risk as I have previously discussed. The main finding of the PCPT trial was that taking finasteride (Proscar™) could reduce the rate of prostate cancer, BUT that there were more high grade cancers in the group taking the drug compared to placebo. As a result of this finding (which has been the subject of extensive discussion and speculation…for example one analysis suggests that this is an artifact of making high grade cancers easier to find because the prostate volume shrinks by about 1/3 in men on finasteride), the FDA issued a warning against taking finasteride or dutasteride. In the article released today, the investigators reported on the long term outcome of the study. As usual, the results are creating much discussion, and differing points of view. Overall there was NO DIFFERENCE in the death rate among men taking finasteride vs. placebo. 78% of men in each group survived 15 years. Moreover, there was no difference in the death rate among men who did develop cancer regardless of whether they were on finasteride or placebo. The investigators suggest this means it is reasonable to take finasteride to reduce the incidence of men who must deal with a diagnosis. Of course another approach (favored by the U.S. Preventive Services Task Force) is not to screen at all (remember all the patients in the trial were being screened by psa testing). Based on these considerations, I think it would be reasonable to recommend finasteride as a preventative in men who have a positive family history. Purists would point out that this has not been tested and would require a prospective trial before making such a recommendation. Where is Diogenes when we need him???

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May 4, 2013 · 9:29 am

The American Urologic Association on Screening


The incredible blowback from various urologists who didn’t share the USPSTF guideline on screening has now been answered by the urologists (or at least their professional organization) themselves. In their just released guidelines, there is a more nuanced approach, but a clear recognition of the risks involved with screening, and adoption of an age-gated approach. Here are the core statements from their website:

Guideline Statement 1: The Panel recommends against PSA screening in men under age 40 years. (Recommendation; Evidence Strength Grade C)

  • In this age group there is a low prevalence of clinically detectable prostate cancer, no evidence demonstrating benefit of screening and likely the same harms of screening as in other age groups.

Guideline Statement 2: The Panel does not recommend routine screening in men between ages 40 to 54 years at average risk. (Recommendation; Evidence Strength Grade C)

  • For men younger than age 55 years at higher risk (e.g. positive family history or African American race), decisions regarding prostate cancer screening should be individualized.

Guideline Statement 3: For men ages 55 to 69 years the Panel recognizes that the decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality in 1 man for every 1,000 men screened over a decade against the known potential harms associated with screening and treatment. For this reason, the Panel strongly recommends shared decision-making for men age 55 to 69 years that are considering PSA screening, and proceeding based on a man’s values and preferences. (Standard; Evidence Strength Grade B)

  • The greatest benefit of screening appears to be in men ages 55 to 69 years.

Guideline Statement 4: To reduce the harms of screening, a routine screening interval of two years or more may be preferred over annual screening in those men who have participated in shared decision-making and decided on screening. As compared to annual screening, it is expected that screening intervals of two years preserve the majority of the benefits and reduce overdiagnosis and false positives. (Option; Evidence Strength Grade C)

  • Additionally, intervals for rescreening can be individualized by a baseline PSA level.

Guideline Statement 5: The Panel does not recommend routine PSA screening in men over age 70 years or any man with less than a 10 to 15 year life expectancy. (Recommendation; Evidence Strength Grade C)

  • Some men over age 70 years who are in excellent health may benefit from prostate cancer screening.

As I have stated elsewhere in this blog, screening is viewed differently by men who have already been found to have prostate cancer, for all kinds of reasons, not least because they wish they were in the happy group of men who are doing fine and may or may not need to be detected. (or they feel that screening saved their life or could have…)

The bottom line remains that the decision is individual, and that going through the pros and cons is not a short discussion in a family practice office, or even less in the line at the 9 Health Fair or similar. It will take you at least 15 minutes to read through the VERY thoughtful AUA statement, which is the best summary I have read in a long time.

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