Screening Prostate-Specific Antigen and Early Detection

Abstract

Prostate cancer early detection based on screening with prostate-specific antigen (PSA) has been a highly controversial topic over the years. Early detection and treatment of high-risk prostate cancer explains a large proportion of greater than 50% reduction in age-standardized prostate cancer mortality observed since the early 1990s. However, this public health success has come at the cost of high levels of overdiagnosis of low-risk tumors, and many men have suffered from overtreatment of these entirely indolent lesions. Data from randomized trials increasingly clearly indicate a prostate cancer mortality advantage with screening. Other cohort studies, moreover, suggest that an early, baseline PSA test around age 45 or 50 years can predict cancer risk over years and decades, potentially allowing subsequent screening intervals to be personalized, further reducing both over- and underdiagnosis. Other aspects of a smarter screening paradigm include focused attention on men at higher risk based on ancestry, family history, and other factors; consideration of other variables together with PSA; selective use of secondary testing with emerging blood and urine tests; and reservation of treatment only for men at risk of prostate cancer mortality. Such an approach should be able to reduce further prostate cancer morbidity and mortality, while minimizing the harms of over-diagnosis and overtreatment. This review contains 4 figures, 1 table, and 88 references. Key Words: Prostate cancer, prostate-specific antigen, early detection, cancer screening, guidelines, risk stratification, epidemiology, PLCO, ERSPC, USPSTF, CISNET