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PSA screening for prostate cancer to start at age 40: new guidelines

Last Updated: 2009-11-24 16:27:46 -0400 (Reuters Health)

November 30, 2009

By Ford Vox, MD

NEW YORK (Reuters Health) - In its first prostate specific antigen (PSA) policy update since 2000, the American Urological Association has lowered the recommended age for screening healthy men for prostate cancer to age 40 from age 50, with the caveat that men must be "well informed" about the risks and benefits.

The AUA summarized its latest PSA guidelines in the November issue of The Journal of Urology. The new summary is a companion document to the full guidelines published in April 2009, and is authored by the same panel members, led by facilitator Dr. Kirsten Greene of the University of California, San Francisco.

Throughout the document, panel members highlight the multiplicity of choices patients and doctors face at every stage, including early detection, pretreatment risk stratification and post treatment management. As in the last set of guidelines, the AUA continues to recommend a combination of PSA testing and digital rectal examination as the most accurate screening regimen.

Weighing evidence that is at times conflicting and murky, the AUA panel consistently sides with patient autonomy and physician judgment. They expressly warn that the statement does not "pre-empt physician judgment" or "define the legal standard of care."

The drop in the recommended age for starting screening is "more to get a baseline PSA, rather than to say every man needs to get a PSA at age 40," Dr. Greene told Reuters Health.

The panel relies on several key findings to justify the new recommendation. Among these findings is that men with a PSA value above the median for a given age are at greater risk for cancer. They also note that PSA tests are more accurate in younger men, and provide a baseline value for interpretation of future tests.

"Older men have bigger prostates due to benign prostatic hyperplasia (BPH), and younger men have less BPH," Dr. Greene said, meaning that screening younger men will introduce less error. "There are several studies showing that the PSA level of a man in his 40's is actually more predictive of his developing prostate cancer," she added.

No specific PSA number alone should prompt a biopsy, the panel states. PSA levels below 4.0 ng/mL are actually more sensitive in detecting cancers, and while some of those will be clinically insignificant, there is a continuum of risk at all PSA levels, the authors observe. A 50-year-old man with a normal digital rectal exam and a PSA level of 0.0 to 2.0 ng/mL still has a 10% risk of prostate cancer on biopsy.

The statement describes conflicting findings on kinetic PSA measures including PSA doubling time and PSA velocity. The panel considers that using the ratio of free to total PSA may reduce the number of biopsies in men whose PSA is in the moderate range of 4.0 to 10 ng/mL. Depending on the cut points chosen, these PSA analysis methods can increase sensitivity and/or specificity.

In lieu of PSA cut points, biopsy decisions should be "based primarily on PSA and digital rectal exam results but should take into account multiple factors, including free and total PSA, patient age, PSA velocity, PSA density, family history, ethnicity, prior biopsy history and comorbidities."

Similarly, the position statement describes the variety of biopsy procedures available, including the standard 8 to 12 cores, and extended and saturation techniques, without endorsing one over another. The more extensive methods reduce false positive rates and are most appropriate for men with persistently elevated PSA and previous negative biopsies, the panel wrote.

The statement parts with the U.S. Preventive Services Task Force 2008 recommendation to cease PSA screening in men over age 75. Conceding that the value of the PSA test declines precipitously with aging, the AUA panel nonetheless criticizes the USPSTF's universal stand. A clear distinction exists between screening and treatment, the AUA says, and men who have a life expectancy of more than 10 years at any age should be screened.

The practice statement advises against extensive routine use of radiographic staging, including CT, MRI and bone scans, and surgical staging. Gleason scores and PSA levels should guide the aggressiveness of staging efforts.

J Urol 2009;182:2232-2241.

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