PSA Testing: A Brief Note on Current Thinking

Q: What is your current thinking around the PSA test for prostate cancer detection?

A: The death rate from prostate cancer among U.S. men has fallen more than 30 percent since the introduction of the PSA test in 1990, as the result of earlier diagnosis and improved treatments.

But what also resulted in the years after its introduction was overdetection and overtreatment of a substantial number of low-grade cancers that posed no immediate risk to patients. In 2012, the U.S. Preventative Services Task Force published a controversial recommendation against regular preventive PSA screening, based on potential harms caused by overtreatment of low-risk cancers, such as the risk of sepsis from biopsy and treatment-related side effects, including changes in urinary, bowel and sexual function.

Since then, several large, long-term trials (including randomized trials in the U.S. and Europe and a recent cohort study with 16-year follow-up) have established that there is indeed benefit to population-level PSA screening. At the same time, there has been an effort within the urology community to better identify and manage patients with non-lethal cancers who are appropriate candidates for active surveillance regimens. A randomized trial and two large prospective cohort studies support the long-term safety of this strategy in select patients, and recently commercialized gene expression profiling tools have great potential to further improve risk stratification.

This year, the USPSTF updated its PSA testing recommendations, stating that men between the ages of 55 and 69 should make individual decisions on PSA screening with input from an informed provider. Men over 70, however, are still not recommended for PSA screening.

Prostate cancer screening reduces mortality and the burden of metastatic disease, and the paradigm continues to evolve. There is reason for optimism about continued improvement to diagnostic accuracy and a reduction in overdetection, with promising research emerging on second-generation PSA tests, multiparametric MRI and germline genomics testing.

Men who are at risk for prostate cancer because of their age, family history, race or newly identified factors (such as germline genetics) deserve an informed discussion with their provider on the benefits and risks of screening.

— Urologist Eric Klein, MD