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BackTable / Urology / Article
An Overview of Prostate Cancer Screening Guidelines
Lauren Fang • Apr 5, 2024 • 32 hits
Balancing the risks and potential invasiveness of prostate cancer screening tools and treatments against the benefits of early detection has led to a need for more research regarding the optimal prostate cancer screening methodology. The commonly used digital rectal exams and PSA tests have limitations as screening tools, given the lack of clear guidelines and debate regarding the most favorable age range for testing to occur. Urologists Jose Silva and Ali Kasraeian provide insight into current guidelines given by the American Urological Association (AUA) and assert the need for informative patient education to be made a priority when discussing the detection of prostate cancer.
This article features excerpts from the BackTable Urology Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable Urology Brief
•A study performed by Ulmert et al. found that the first PSA level in a man’s early to mid-40s was the most predictive of his future risk of prostate cancer, operating under the assumption that the patient initially had an average risk of prostate cancer. For example, men who had a PSA above 1.5 represented about 44% of men who had clinically significant prostate cancer later in life.
•Both race, specifically African American, and family history of prostate cancer are risk factors for the development of prostate cancer. In these instances, it may be advantageous to test PSA levels earlier in life, closer to 40 years of age.
•PSA screening guidelines remain controversial, so it is ultimately up to the patient and physician to discuss the risks and benefits. The goal of the screenings is to detect cancers while they are still confined to the prostate, as the rates of remission approach 95-100% in these early detection cases.
Table of Contents
(1) Prostate Cancer Detection: PSA Screening
(2) Shared Decision-Making & Patient Education
Prostate Cancer Detection: PSA Screening
Prostate cancer screening guidelines are constantly changing as new research and data becomes available, leading to an unsteady landscape for patients and physicians alike. Most recently in 2018, the United States Preventative Services Task Force (USPSTF), alongside the AUA, stated that the recommended age for PSA screening is for men between the ages of 55-69 years, following the informed decision from the patient with the guidance of their clinician. Furthermore, the USPSTF cautions against PSA-based screening for men age 70 or older, as the potential benefits do not often surpass the expected harm for patients in this age cohort. In addition to the USPSTF recommendations, the AUA discourages early screening, specifically for men younger than 40, because of the adverse affects of both biopsies and treatments on this age group. The middle age range, 40-54 years, is where the majority of discrepancies in prostate cancer screening recommendations lie. The AUA typically leaves the decision up to the discretion of patients and physicians. However, at an average risk of prostate cancer, meaning the lack of racial factors and family history that may increase the likelihood of early development, the AUA aires on the side of caution and recommends against PSA screening.
[Dr. Ali Kasraeian]
Prostate cancer [is] a cancer that men often are afraid to talk about. That desire to avoid screening, avoid therapies and things of that nature, I think, is a very, very important thing for us to talk about as clinicians and is an important thing for us to be mindful as we talk about the topic we're discussing today.
[Dr. Jose Silva]
Let's talk about prostate cancer screening. At what age did you start? Are you following the guidelines? The guidelines, you were already practicing when the guidelines came in, and I was fascinated. What was the trend? One day, it's okay to screen up a guy 44 years old and the next day, then you have to wait 11 years to 55 years old. How's your practice?
[Dr. Ali Kasraeian]
If we look, the guidelines are so confusing. If you look for you and I, as urologists, we keep up with this stuff, and those people that are dealing with prostate cancer on a daily basis, we keep up with this quite a bit, and even then it's very controversial. Prostate cancer is one of the most controversial cancers that urologists, neurological oncologists, medical oncologists, and practitioners, in general, deal with. You can imagine for the primary care doctors, this has to be really, really difficult to deal with, and for men in general, this has to be very confusing.
We constantly change what information we put out there, every organization seems to have a different guideline. What I seem to like, and what makes a lot of sense. It comes from a study I read some years ago, they came out of Malmo, Sweden that some colleagues of mine, from Memorial Sloan Kettering and other institutions, seem to be involved in and it resonates with me, and it makes a lot of sense. In this study, they looked at a large number of men, over 25,000 men, that they followed for their lifetime. This was a study looking at the natural history of disease.
They went back and found these men's blood in freezers and they looked at the PSA. They found that the first PSA in your mid to early 40s was the most predictive of your future risk of prostate cancer. This is going to be clinically significant in your lifespan, your quality of life, so that's impactful, and this was for men with average risk of prostate cancer. They found that men who had a PSA above 1.5 represented about 44% of men who had clinically significant prostate cancer later on in their life. That's very profound.
They found that men who had a PSA less than 1 may not potentially have clinically significant prostate cancer anytime in their life. They had a follow-up study for men that had PSAs less than 1 at 60. They actually may never have clinically significant prostate cancer. If you look at the Memorial Sloan Kettering website, it talks about their screening protocols. They follow a very regimented algorithm based on this pathway, which makes a lot of sense.
For me, having a PSA, if you're a normal-risk person with no family history of prostate cancer, you're not of African ancestry or you're not African American, having a PSA around [age] 45 makes a lot of sense. If you have a family history, if you're African American, having a PSA somewhere closer to [age] 40 makes a lot of sense. Then you can come up with a game plan as to how often to get a PSA, potentially getting a PSA sooner.
If your PSA is much higher at those ages, [think about] talking to a urologist sooner. Talking about getting a smarter screening regimen. We'll talk about things like biomarkers, the multi-parametric MRI. We have a lot of tools that are designed to avoid unnecessary biopsies [while also making] sure we're not missing a reason to do a biopsy and miss a cancer that's clinically significant.
Nowadays, we have so many other tools that are emerging and are going to continue to emerge like focal therapy that are looking to manage disease with less side effects and less morbidity. How we manage prostate cancer is going to be much different. Active surveillance has changed the conversation. There are a lot of controversial discussions about whether or not Gleason 6 prostate cancer is even-- you've had a whole other discussion about it. You and I could spend hours having that discussion.
[Dr. Jose Silva]
Exactly.
[Dr. Ali Kasraeian]
It's a controversial challenge. One thing we as urologists can do is try to make it a little bit more simplified so our primary care doctors and the men going to those primary care doctors could have better, more simplified discussions. We don't keep men who need to be screened away from screening.
[Dr. Jose Silva]
Exactly. When the guidelines came out, what I'm seeing is that most of the primary care in the areas are just waiting for the patient to be 55. Then suddenly that 55 patient asymptomatic has a PSA in 7. What do you do then?
[Dr. Ali Kasraeian]
The challenge with that recommendation is the AUA, when they created that task force, they put a pretty high standard for that task force to bear where you had to have randomized level A evidence to make recommendations. That's a very, very difficult level of data to find where you have level 1 randomized clinical control trials. Those don't always exist. There are trials that are pretty good trials that don't necessarily have to be randomized control trials to let us know that screening and early screening can potentially save lives.
[Dr. Jose Silva]
Yes. Personally, in the office, I'm not going to do a PSA on somebody asymptomatic at less than 40, but more than 40, I see a lot of Hispanics. There's data that Hispanics have more chances of higher-grade cancer. I started doing the PSA at 40. It becomes a challenge. Like you said, patients that had a 0.8, 0.6, are you going to do it yearly? Are you going to do it every two years? That's when it's different. Sometimes if you do every two years, that patient might forget. At least in my practice, I do it yearly, or I recommend doing it yearly, but it's always changing. [chuckles]
[Dr. Ali Kasraeian]
That's the challenge with this aspect. It makes it easy if you make the conversation easy. If you simplify for a patient. A lot of our patients that we see as urologists, often when they come in with an elevated PSA, they don't even know why they're there. This idea of having a personalized discussion with your primary care doctor about whether or not to get a PSA, that's a very difficult thing to potentially put all of that on a primary care doctor that has maybe 10 to 15 minutes to talk to their patient about everything under the sun.
We have to be a little bit realistic about the implications of a personalized discussion about screening with a population that often may have other things on their mind when they're going to their primary care doctor. They may not have all the information about prostate cancer screening. For urologists to lead that discussion, often when we see the patient, they've already had a PSA that's elevated. We often do not see the patients for prostate cancer screening when they have a low PSA, unless we're seeing for other reasons and we have the opportunity to do that. That's not usually the prostate cancer screening patient.
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Shared Decision-Making & Patient Education
Trends from 2014 to 2019 have shown a steady increase in the incidence of prostate cancer in a variety of age groups of men. While most forms of prostate cancer are slow-growing and non-agressive, early detection remains a vital factor in the prognosis of patients. Screening allows for the detection of prostate cancers prior to metastasis to other parts of the body. Since the screening guidelines are constantly evolving, Dr. Kasraeian assets the need for detailed patient education prior to the decision making process, as knowledge is a powerful tool for patients to manage their own health and wellbeing. Furthermore, the ability for the patient to weigh the pros and cons of the various prostate cancer screening options prior to the procedure enables the patient to bring their personal priorities into the conversation.
[Dr. Jose Silva]
Ali, anything else you want to add in terms of patient advocacy? What makes the patient more comfortable?
[Dr. Ali Kasraeian]
One of the things to be mindful of is knowledge. Knowledge is power and educating the patients for understanding the reasons why for everything, whether it's prostate cancer, whether it's BPH, whether it's anything when you empower them to be their own best advocate and for them to understand the why of the discussion in this case, why is it important to screen? Why is it important to choose whatever the next step is? Why are we getting the MRI scan? Why are we doing the biomarker and engage them in the process, they become their own best advocate and they become partners in the decision-making.
I'm not and I never will be the doctor that tells a patient what to do especially in the realm of prostate cancer treatments, for example.
Every treatment has its own very specific risks and benefits, and every patient needs to be mindful of that and their personal decisions or personal opinions of what that is. I tell them there are four types of prostate cancer in my opinion: there are rockets, rabbits, turtles, and snails. We are screening and the whole reason to screen is to avoid rockets. Those are the cancers that are metastatic and or get metastatic.
The rabbits are the prostate cancers that have legs, those are the Gleason 7s, 8, 9s, and 10s. We are screening to catch those at a time that we can catch them while they're confined to the prostate so that we can treat them at a time where our treatments are curative. Our cures approach close to 95% to 100% cure when they're confined to the prostate.
The controversies for prostate cancer arise with the turtles and the snails. Those low-volume, low-risk prostate cancers that are not fatal and that's where the controversies for prostate cancer from screening to treatment to overtreatment to overdiagnosis comes up. Where we can continue to strive to do better is how to be smarter in screening, smarter in advanced diagnostics, and continue to push the envelope on less invasive and treatment options.
With screening, one of the things that we have to be mindful of is recently the American College of Surgeons put out some numbers where there was a decrease in certain cancers over time and there was some celebrations and wonderful news for certain cancers like cervical cancer.
They found that there was a 3% increase in prostate cancer incidents each year from 2014 to 2019 and that's about 99,000 new cases. This is the first time in 20 years that we've seen an increase in the incidence of prostate cancer and that translates. In 2023 we're going to see 28,300 new cases of prostate cancer with 34,700 deaths. These numbers are continuing to elevate where several years ago people remember numbers were in 188,000, so those numbers were lower.
This is attributable very much in large part to those changes in screening recommendation and they come out and say that. Other factors could be a part of that, however, we have to be mindful of that. We've seen papers written in terms of the stage migration increase in more metastatic disease and if we're not mindful of that and we don't be smart about how we discuss appropriate screening, we don't have those conversations and be mindful of the recommendations we make to our primary care colleagues, we don't educate the men in our community, the African American population with family history, engage men in terms of how we do biopsies that are less painful with less side effect and have men just go in and get screenings, PSA tests, make them not all afraid of the rectal exam potentially, we're going to have men that are going to show up with more advanced disease.
That's going to be a big shame because we're at a time where we're looking at better technologies, imaging that lets us do better biopsies that can let us be more targeted. We're pushing the envelope of more and more novel technologies that lets us do more focal therapies that preserve more prostate and preserve more function.
Over the past five to 10 years we're pushing that envelope for prostate cancer. If we do it responsibly and follow the data, we can change how prostate cancer is managed. We just have to educate our colleagues and our primary care doctors and the men in our communities that way and make sure that we reverse this tide because prostate cancer unfortunately can kill and it's a shame because it shouldn’t.
Podcast Contributors
Dr. Ali Kasraeian
Dr. Ali Kasraeian is a private practice urologic oncologist in Jacksonville, Florida.
Dr. Jose Silva
Dr. Jose Silva is a board certified urologist practicing in Central Florida.
Cite This Podcast
BackTable, LLC (Producer). (2023, March 8). Ep. 85 – New Technologies for Prostate Screening [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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