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Latest PSA Testing Recommendations

Prostate cancer, which was described as a “very rare disease” in the 19th century, is now the most common male cancer, and the second most common cause of cancer-related death in men in the United States.

A blood test to measure levels of prostate-specific antigen (PSA) was first approved by the Food and Drug Administration in 1986 as a way to determine whether prostate cancer had been treated successfully and to monitor for its recurrence. Today, PSA tests are approved for prostate cancer detection and are widely used to screen men for the disease.

The PSA test measures an enzyme produced almost exclusively by the glandular cells of the prostate. An abnormality of the prostate can disrupt the normal architecture of the gland and create an opening for PSA to pass into the bloodstream. Thus, high blood levels of PSA can indicate prostate problems, including cancer. PSA blood levels are expressed as nanograms per milliliter (ng/mL).

Clinical studies, including a large randomized trial known as the European Randomized Study of Screening for Prostate Cancer (ERSPC), have shown that PSA testing saves lives by allowing earlier detection and treatment of the disease.

PSA drawbacks

Because some of the cancers detected by PSA screening are so small or slow growing that they might never become life threatening, the trade-off of routine screening is the over-diagnosis of non-life-threatening cancers for which treatment is not necessary. This occurs more often in older men, who have less to gain from screening because of a shorter life expectancy. A particular problem is that most low-risk cancers are nonetheless treated, leading to treatment side effects such as incontinence and impotence.

Another drawback of PSA testing is that most men with an elevated PSA do not have prostate cancer. Instead, benign prostatic enlargement (BPE) or inflammation is to blame. These men may undergo unnecessary diagnostic tests and treatments and may experience undue anxiety. Because of these uncertainties, men should discuss both the benefits and limitations of PSA testing with their physician before having their PSA levels measured.

There is no PSA level below which physicians can reassure a man that he does not have aggressive prostate cancer. Aggressive cancer for PSA below 1 to 2 ng/mL is very rare.

For older men, levels above 3 to 4 ng/mL usually indicate that a prostate biopsy should be considered. Most experts agree that PSA screening should be used in conjunction with other information, in particular, a physical examination and history to determine whether the PSA rise could be related to benign disease. The biopsy should only be performed following a discussion with the patient about its benefits and risks.

Promo block

Some doctors and researchers have questioned the benefits of PSA testing in light of the fact that it may detect slow-growing prostate cancer and result in unnecessary treatment and side effects. In fact, in 2012 the U.S. Preventive Services Task Force recommended that PSA testing no longer be used as a prostate screening test, and awarded it a grade of D, one of the lowest possible. The panel members felt there was sufficient certainty that the test had no net benefit and that the harms of testing outweighed the benefits.

Recommendations

I support the Memorial Sloan-Kettering Cancer Center guidelines for prostate cancer screening. We believe that the data support starting screening earlier—at 45 years of age—and that most men should stop screening at age 60.

I, along with other Memorial Sloan-Kettering Cancer Center experts, believe that PSA testing saves lives, and we have been working to determine smarter ways to screen men to ensure that those at higher risk for aggressive prostate cancers can be diagnosed and treated, while those at lower risk can avoid unnecessary treatment.

Our prostate cancer guidelines at Memorial Sloan-Kettering Cancer Center are based on the following principles: Many men with prostate cancer do not need to be treated and can be followed by active surveillance. A diagnosis of prostate cancer is information used to help make decisions, not an indication for immediate treatment.

Compliance with screening will increase if men are told whether they are at high, intermediate, or low risk and are informed about their need for subsequent screening.

There is a balance between the harms and benefits of screening. By focusing screening on men at highest risk of life-threatening prostate cancer, we can better achieve this balance.

PSA testing schedule

When it comes to PSA testing, the following PSA screening guidelines apply to men expected to live at least 10 years.

Promo block

Men ages 45 to 49 should have a baseline PSA test, and:

• If the PSA level is 3 ng/mL or higher, they should talk with their doctor about having a biopsy of the prostate.

• If the PSA level is between 1 and 3 ng/mL, they should see their doctor for another PSA test every two to four years.

• If the PSA level is less than 1 ng/mL, they should see their doctor for another PSA test at age 51 to 55.

Men ages 50 to 59 should have their PSA level checked, and:

• If the PSA level is 3 ng/mL or higher, they should talk with their doctor about having a biopsy of the prostate.

• If the PSA level is between 1 and 3 ng/mL, they should see their doctor for another PSA test every two to four years.

• If the PSA level is less than 1 ng/mL, they should see their doctor for another PSA test at age 60.

Men ages 60 to 70 should have their PSA checked, and:

• If the PSA level is 3 ng/mL or higher, they should talk with their doctor about having a biopsy of the prostate.

• If the PSA level is between 1 and 3 ng/mL, they should see their doctor for another PSA test every two to four years.

• If the PSA level is less than 1 ng/mL, no further screening is recommended.

Men ages 71 to 75 should talk with their doctor about PSA testing, and:

• The decision whether to have a PSA test should be based on past PSA levels and the man’s current health status.

Beyond PSA testing

Based on initial PSA testing, there are many new tests available that allow us to say with greater confidence who is likely to have a biologically significant prostate cancer and who is not, who should be biopsied, who should not, who needs treatment now, who can enter an active surveillance program, and, in the case of men who have had surgery for their cancer, who will benefit from additional treatment.

Andrew Vickers, Ph.D., is an attending research methodologist in the Department of Epidemiology and Biostatistics at Memorial Sloan-Kettering Cancer Center.

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