In 2012, the U.S. Preventive Services Task Force (USPSTF) published its recommendations against routine PSA screening.3 This caused men aged 50 to 54 to be less screened, with just 18% getting a PSA test in 2013 compared to 23% in 2010.4 Most recently, in 2017, the USPSTF updated its recommendations and suggested individualized, informed decision-making regarding PC screening in men aged 55-69.5 However, no guidance was given for men younger than 55.
The decision of whether to initiate early PC detection is controversial. PSA screening has caused significant downward stage migration at diagnosis since 1988,6 with a significant drop in the incidence of metastatic PC at the time of diagnosis.6, 7 However, PSA screening can cause over-detection of indolent disease, which can safely be left undiagnosed and untreated.
Studies have shown that a single PSA test before the age of 50 predicted subsequent PC development up to 30 years later with an area under the curve of 0.72.8 Furthermore, the risk of PC death was strongly correlated with baseline PSA in men aged 45-49, with 44% of the deaths occurring in men with the highest percentile of PSA distribution.9 This evidence should lead us to at least consider baseline testing in men younger than 50 using a shared decision making model. In our center, a more aggressive strategy has been used among young patients under 50 with PSA close to 1 and above. In this study, our objective was to examine this adopted strategy and describe its resultant detection rates of any and clinically significant PC.
We analyzed all first prostate biopsies (PBs) in men younger than 50 with a pre-biopsy PSA<2.5 ng/ml at the Princess Margaret Cancer Centre between 2000 and 2016. A total of 199 patients were analyzed. Mean patient age and prostate volumes were 46 years and 29 cc, respectively. Approximately a fifth of patients younger than 50 with a PSA<2.5 ng/ml were diagnosed with PC. Interestingly, 2/3 of patients diagnosed with cancer had PSA levels above 1.5 ng/ml, and more than half had disease with pathology exceeding that of the Epstein criteria for AS. Furthermore, more than 20% had Gleason 7 or worse disease, and these all had a PSA above 1.5 ng/ml (Figure 1). Positive family history (OR 3.43, 95% CI 1.455-8.147), lower prostate volume (OR 0.932, 95% CI 0.876-0.991), and rising PSA (OR 2.347, 95% CI 1.133-4.863), were all demonstrated to be predictors of PC diagnosis. Positive family history (OR 9.043, 95% CI 2.678-30.535) was shown to be the sole predictor of PC with pathology exceeding that of Epstein criteria.
Current urologic guidelines do not routinely recommend PSA testing for men younger than 50, and although screening is important, it is only the initial step. Deciding what constitutes a high PSA in young men, and whether it should result in a referral for a PB, are the next critical steps. In our opinion, the presented data justifies consideration of an aggressive PB strategy for men younger than 50 with a PSA>1.5 ng/ml, as well as a conservative approach for those with PSA <1.5 ng/ml. Special attention should be paid to patients with a family history of PC, and smaller prostates, even at lower PSA values.
Written by: Hanan Goldberg, MD, Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Ontario, Canada @GoldbergHanan
References:
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https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementDraft/prostate-cancer-screening1 Accessed 24th December 2017. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementDraft/prostate-cancer-screening1.
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