SIU 2018: Prostate Cancer Screening: American Perspective

Seoul, South-Korea ( Matthew Cooperberg, MD gave a presentation on prostate cancer screening from an American perspective.  Prostate cancer is the most prevalent cancer in the US and the second highest cancer causing mortality in men (Figure 1). The goal of screening is to find aggressive prostate cancer early and cure it before it spreads beyond the prostate. Most cancer cases found by screening do not need to be treated and can be safely managed with active surveillance.

UroToday SIU2018 Prostate cancer data in the USA in 2018
Figure 1 – Prostate cancer data in the USA in 2018:

In 2012 the US Preventive Services Task Force (USPSTF) basically recommended against PSA screening for prostate cancer. This has caused a significant drop in the incidence of prostate cancer diagnosis (Figure 2). Unfortunately, racial disparity has not narrowed with time, with more African Americans being diagnosed than Caucasians (Figure 3).

UroToday SIU2018 Incidence of prostate cancer through the years
Figure 2 – Incidence of prostate cancer through the years compared to other cancers:

UroToday SIU2018 Racial disparity in prostate cancer
Figure 3 – Racial disparity in prostate cancer:

There are three important randomized prospective trials on PSA screening:

  1. The ERSPC trial (1)– demonstrated that screening resulted in a 21-29% relative reduction  in prostate cancer mortality
  2. Goteborg trial (2) – demonstrated a 42% relative reduction in prostate cancer mortality
  3. PLCO trial (3) – Non-informative study with respect to the question of screening vs. no screening
The guidelines in 2018 are approaching a consensus with the American Urologic Association (AUA) guidelines recommending shared decision making  for men aged 55-70, with no recommendation for men aged 40-54, and against screening for men aged >70. No specific recommendation for African-Americans was given. The National Comprehensive Cancer Network (NCCN) guidelines recommend shared decision making for men aged 45-75, with a recommendation to start screening “several years earlier” for African American men. Lastly, the American Cancer Society (ACS) guidelines recommend shared decision making for most men starting at age 50, and for African-American men or for those with known risk factors to start at an age of 40-45. The USPSTF had later changed their recommendation to shared decision making for men aged 55-69, and against screening for men aged >70, with no specific recommendation for African Americans.

There is value in establishing an early baseline of PSA levels. If the PSA is less than 1 ng/ml at the age of 60, the likelihood of prostate cancer death is less than 0.3%. Over 90% of prostate cancer deaths occurred in men with a PSA above 2 ng/ml (top quartile) (4). However, PSA should not be interpreted in a vacuum alone. The patient’s age, family history, digital rectal examination, and history of previous prostate biopsy should all be taken into account. Additionally, there are other tests that should be considered in addition to and after PSA. These include mpMRI, PET PSMA, urinary biomarkers such as PCA3 test, and SelectMDx, and blood biomarkers – phi (PSA, free PSA, 2proPSA), 4K test (PSA, free PSA, iPSA, HK2).

Risk stratification is important before treatment. The goal is to inform physician-patient decisions about optimal initial treatment approach and timing. Active surveillance is being utilized more commonly in the real world with 40% of the patients with low grade disease being monitored with active surveillance. (5) Although this number is still low, it is rapidly progressing.

In summary, screening should be offered to healthy men with good life expectancy. It is important to tailor the intensity of screening based on race/family history and baseline PSA. Nearly all low-risk prostate cancers should be managed with active surveillance. The treatment of patients must be of high quality. This should be a collaborative group effort including the primary physician, the urologist, the patient and his community.

Lastly, the PSA cut-offs for screening that should be used according to Dr. Cooperberg are as follows:

  • - For age 45-60, PSA less than 1 – recheck in 5+ years, PSA 1-2 – recheck n 6 -12 months vs. early referral for prostate biopsy based on family history, and anxiety. PSA >-2 – the patient should be referred for a biopsy. For age 61-75, PSA <1 – recheck in 5+ years, PSA 1-3 – recheck in 6-12 months vs. early referral for prostate biopsy based on family history, and for PSA above 3 ng/ml – the patient should be referred for a prostate biopsy.

Presented by: Matthew Cooperberg, MD, UCSF, USA

1. Schroder et al. Lancet 2014
2. Onsrud Godtman R et al Eur Urol 2014
3. Andriole et al, JNCI 2012
4. Vickers et al. BMJ 2013
4. Copperberg et al. JAMA 2015

Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre  Twitter: @GoldbergHanan at the 38th Congress of the Society of International Urology - October 4- 7, 2018 - Seoul, South Korea 

Read More:
Prostate Cancer Screening: Japanese Perspective
Prostate Cancer Screening: Latin American
Prostate Cancer Screening: European Perspective