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Home » EU Health, Health, Prostate Cancer

PSA testing: A more informed approach

Submitted by on 14 Jul 2017 – 10:00

By Chris Booth, Trustee, CHAPS Men’s Health Charity

Despite continuing controversy, (1) for the foreseeable future the blood test Prostate Specific Antigen (PSA) remains the only initial, simple, cheap option available to screen for Prostate Cancer (PCa) in asymptomatic men to detect PCa at an early, curable stage.

Nearly all western national and international urological guidelines recommend PSA-based screening for appropriately selected, counselled men who can then make an informed decision. (2, 3, 4) In summary, the majority of international expert panels recommend or propose:

• Screening from age 45 for men with a family history of an immediate male relative with PCa and black African or African Caribbean men (risk 1 in 4).

• Obtain a baseline PSA in a man’s forties to predict future risk.

• Link PSA to a “risk calculator” to assess need and frequency of future PSA testing.

• Do not screen men below 40 or with less than 10 years’ life expectancy.

The most reliable clinical trial evidence in support of these recommendations comes from Europe where reductions in PCa mortality of up to 51% have been demonstrated. (5, 6)  Despite this a number of national agencies continue to advise against PSA screening. (7, 8) on the basis that the “harms” of “over-diagnosis” and “over-treatment” of non-aggressive PCa outweigh its benefits in terms of lives saved.

In addition to this European screening evidence, two very important UK trials were published in 2016 that go a considerable way to answering the problems of over-diagnosis and over-treatment of screen-detected, non-aggressive PCa.

The PROMIS Trial

This trial (9) of multiparametric MRI (mpMRI) showed that only prostate glands with lesions demonstrable on mpMRI needed biopsy.  If no lesion was visible, it could be safely assumed that any underlying PCa present would be non-aggressive.  mpMRI should therefore be performed before biopsy.

The ProtecT Trial

This reports the 10 year clinical outcome of 1643 men with apparent, non-aggressive, PSA screen-detected PCa randomised to receive radical treatment or active surveillance. (10)  After 10 years’ follow-up, the death rate was only 1% whether treated initially or followed on active monitoring, though in the latter group over half the men on surveillance developed progression and changed to active treatment.

Presumably, without screening in the first place, these men would have presented with late stage, incurable disease and most likely added to our PCa death toll.  This progression rate is not surprising given the limitations on the accuracy of standard TRUS biopsies during the trial period 1999-2009.

In conclusion, we now have emerging evidence that appears to support PSA-based testing for appropriately informed men backed up by further evidence that shows how we can now avoid the pitfalls of over-diagnosis and over-treatment. It is therefore essential that this positive information is disseminated as widely as possible and especially to those countries where men are discouraged from PSA-based screening and PCa death rates lag behind the best in Europe.

References:

1. Academy of Medical Royal Colleges;  Choosing Wisely UK, Oct2016

2. EAU:  European Urol 2013; 64: 347-54

3. AUA:  AUA Guideline:  http://www.aua.net.org/education guidelines/prostate-cancer-detection.  Accessed 2/11/16

4. Melbourne Consensus:  BJU Int 2014; 113: 186-8

5. Lancet Oncol, 2010, 1: 725-732

6. European Urol 2014; 65: 329-36

7. UKNSC:  Screening for Prostate Cancer Review 2015 update

8. US Preventive Services Task Force.  Accessed Jan 2017

9. PROMIS Trial:  J Clin Oncol 2016; 34 (suppl; abstr 5000). ASCO 2016

10. ProtecT Trial:  NEJM 2016; 375: 1415-1424