PSA Screening: A Discussion Based on the USPSTF Recommendations and the AUA and EAU Guidelines

Abstract

The role of prostate-specific antigen (PSA) screening in the adult male population is not clearly defined. Although PSA has been shown to be the single most significant predictive factor for identifying men at increased risk of developing prostate cancer (PCa), PSA screening may lead to an increase in unnecessary prostate biopsies, significant over-diagnoses of PCa, and overtreatment of the disease, each of which may contribute to untoward complications and/or side effects. We reviewed PubMed and MEDLINE for articles published between 1970 to December 2013 that discuss the clinical applications of PSA as a screening test, in addition to clinical trials, evidence-based recommendations and guidelines from major medical organizations both in the U.S. and worldwide regarding prostate cancer screening. We also reviewed the current PSA screening recommendations of the United States Preventive Services Task Force (USPSTF), the American Urological Association (AUA), and the European Association of Urology (EAU). A total of 110 publications were reviewed. Results from the European Randomized Study of Screening for Prostate Cancer (ERSPC), the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, and Göteborg trials regarding prostate screening are conflicting: The ERSPC and Göteborg trials show a reduction in prostate cancer mortality, but the PLCO trial shows no benefit. The USPSTF has assigned a grade D recommendation to PSA screening, that is, it has recommended against screening for men in the general U.S. population, regardless of age. The AUA updated its guideline in 2013 to reflect its belief that men under the age of 40 or over the age of 70 with less than a 10- to 15-year life expectancy should not be offered or subjected to PSA screening. Men between the ages of 40 and 54 with risk factors (positive family history or African American race), or men of average risk between the ages of 55 and 69 or older if life expectancy is greater than 10 years should be counseled on the risks and benefits of PSA screening and undergo PSA screening if desired. The EAU recommends obtaining a baseline PSA at age 40 to 45 and adapting subsequent screening intervals to that baseline. The diversity of methodology from randomized trials such as the PLCO, ERSPC, and Göteborg, allows for significant flexibility in interpretation, making it difficult to apply trial outcomes to substantiate universal recommendations. Clinical factors, such as age, race, family history, 10-year life expectancy, and patient preferences, should be taken into account. Variations on PSA-based screening, including age-adjusted PSA, PSA density (PSAD), PSA velocity (PSAV), and percentage of free PSA (%fPSA), may be used to improve the performance of the test. PSA testing may serve as the foundation for a more risk-based assessment. Finally, it should be noted that the decision to screen or not to screen using PSA testing is best made by the patient and his urologist after weighing its advantages and disadvantages.