Chapter 1 - Population Screening for Prostate Cancer and Early Detection

Abstract

Population screening for prostate cancer (PCa) is a very controversial and hot topic! In the first 20 years from adoption of the prostate-specific antigen (PSA) test, some organizations supported population-based screening as PSA testing came into widespread use. However, in May 2012, the US Preventive Services Task Force (USPSTF), a government-supported organization, issued a recommendation that PSA testing no longer be performed. In fact, this was not just a guideline against population-based screening but in using PSA in any early detection program. Updated results from the European Randomized Study of Screening for Prostate Cancer (ERSPC) trial show that PSA-screened patients have a lower PCa-specific mortality that has further improved with longer follow up. The USPSTF and other organization committees do not separate the distinction between risks of PSA screening and treatment of diagnosed PCa and this muddies the water with regard to shared decision discussions. The USPSTF only considered mortality in their analyses, ignoring the burden of suffering from advanced cancer. Recent analyses of the ERSPC trial data show a lower rate of progression to metastatic disease and improved quality of life scores for the screened patient population. Furthermore, the USPSTF did not acknowledge that “active surveillance” is also a standard-of-care treatment approach. They did not make any exception to their recommendation to discourage PSA testing even for those with a familial history of PCa, nor for individuals of African ancestry and other ethnic groups with known higher PCa incidence and mortality rates. In 2013, the American Urological Association (AUA) revised their guidelines also recommending against population-based screening, but advocating for informed decision and generally recommending PSA testing every-other-year for healthy men between the ages of 55 and 69. The AUA, however, abandoned its support for a baseline “risk-stratification” PSA test for young men in the 40s age group. The National Comprehensive Cancer Network (NCCN) and the American Society of Clinical Oncology advocate for a shared decision between patients and their caregivers and do not favor blanket population-based screening. I favor joint decision making based on a patient and physician dialogue concerning the need for PSA screening. I also support the use of a baseline PSA test as a risk stratification tool. This chapter will review the PSA controversy and provide data to support rational early detection methods for PCa.