Topic: Prevention and Screening

Changes in Prostate Cancer Presentation Following the 2012 USPSTF Screening Statement

Joseph C. Presti, Jr., MD, FACS, urologist at Kaiser Oakland and Regional Leader of Urologic Oncology Surgery for Kaiser Permanente California, reviews data compiled by Kaiser Permanente Northern California in order to discuss how the 2012 United States Preventive Services Task Force (USPSTF) screening statement, which includes the claim that “the harms of screening outweigh the benefits,” has impacted prostate cancer screening practices. Dr. Presti outlines the research process used, which included looking at screening-eligible men and assessing the annual rates of PSA testing, prostate biopsy, cancer incidence, and metastatic disease incidence over the course of a pre-guideline period (2010-2011) and a post-guideline period (2014-2017). The researchers found that although the eligible screening population grew from 404,000 to 524,000, screening rates decreased from 42% to 29%, biopsy rates went from 1.2% to .5%, and prostate cancer detection decreased from 2063 diagnoses to 994 in 2014 but increased to 1528 in 2017. Concerningly, metastatic prostate cancer incidence increased significantly post-statement. Dr. Presti concludes by summarizing the data and discussing the strengths (ability to define a screening-eligible population and a large, diverse sample size) and weaknesses (inability to access family history or look for indolent cancers) of the study.

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Improving Specificity of PSA Screening with Serum and Urine Markers – Who Doesn’t Need a Prostate Biopsy?

Daniel W. Lin, MD, Chief of Urologic Oncology at the University of Washington, discusses improving the specificity of PSA screening using serum and urine markers to determine which patients do not need a prostate biopsy. He lists the ideal biomarker characteristics, including sensitivity and specificity, correlation with disease outcome, reproducibility, low cost, quick and easy assay, and high negative predictive value. He then discusses some of the major studies done on pre-diagnosis biomarkers for prostate cancer, highlighting how PHI score, 4Kscore, and PCA3, among other markers, all significantly reduce the biopsy rate compared with older diagnostics like percent free PSA. Dr. Lin concludes by noting how urologists can further reduce unnecessary biopsies through smart screening strategies, including biennial rather than annual PSA screenings and considering not biopsying men with low early PSA scores.

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Prostate Cancer Screening and Early Detection: Should We Follow the NCCN Guidelines? Con Argument

Robert E. Donohue, MD, argues against urologists adhering to the National Comprehensive Cancer Network (NCCN) Prostate Cancer Screening and Early Detection Guidelines. He proposes his own definitive answers to controversial questions relating to the use of digital rectal exams and PSA tests in baseline evaluation, indications for biopsy and biopsy technique, the age for initiation and discontinuation of testing, the frequency of testing, screening in high-risk populations, and which biomarkers to use. 

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Prostate Cancer Screening and Early Detection: Should We Follow the NCCN Guidelines? Pro Argument

A. Karim Kader, MD, PhD, argues that although PSA-based prostate cancer screening is flawed, urologists should adhere to the National Comprehensive Cancer Network (NCCN) Prostate Cancer Screening and Early Detection Guidelines. He outlines how, in order to avoid overdiagnosis and other issues, urologists can be more judicious as to which patients are offered screening, biopsy, and treatment, while not abandoning the use of PSA as a marker for prostate cancer altogether.

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State of the Art in “Smart” Prostate Cancer Screening: Defining the Need for Precision Diagnostics

Sigrid V. Carlsson, MD, PhD, MPH, discusses the evolution of attitudes toward PSA screening for prostate cancer over time, and the importance of implementing the PSA test in a way that will truly benefit patients. She details how risk-stratifying algorithms and calculators, biomarkers, and MRI can play a role in refining prostate cancer screening.

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The Staggering Benefit of PSA Screening in Potentially Lethal Prostate Cancer

Patrick W. McLaughlin, MD, discusses the limitations of evidence that provide the basis for the United States Preventive Services Task Force’s (USPSTF’s) negative gradings for PSA screening. He argues that in the modern era, with the currently-available curative therapy for most lethal prostate cancers, intensive screening can allow early enough detection to provide patients opportunities for a cure. 

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Screening for Prostate Cancer: PSA: Why 1.5 is the New 4.0

E. David Crawford, MD, argues for using PSA levels of 1.5 ng/mL as the cutoff point for determining prostate cancer risk in routine screening. He discusses the need for utilizing better risk-assessment methods for detecting prostate cancer, such as genomic markers, in order to reduce unnecessary biopsies, over-detection of indolent disease, and reliance on PSA testing alone.

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TRUS Biopsy, MRI, and PROMIS Trial

John W. Davis, MD, discusses the lack of consensus regarding the definitions and benefits of focal therapy for prostate cancer. He defines the patients who would benefit most from focal therapy, as well as overcoming current challenges in this approach.

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