Optimal use of prostate specific antigen for prostate cancer screening

Prostate cancer (PCa) and prostate specific antigen (PSA) screening have been the main focus of discussions among urologists and primary care physicians during the last few years . Ever since its introduction in the 1980s , PSA screening was implemented as standard of care in many developed countries, but without the supporting level I evidence to justify its initiation (mainly relating to reduction in cancer-specific mortality). Several retrospective reports, such as the Surveillance, Epidemiology, and End Results (SEER) database review suggested a significant decline in mortality rates of 32.5% from PCa due to screening; the Baltimore Longitudinal Study of Aging (BLSA) showed that PSA levels increased years before clinically detectable PCa and that this could lead to an effective early diagnosis and more effective therapy . Similar findings were observed in the study from Tyrol, Austria, where men from this particular region had a notable decrease in mortality after being screened with PSA in comparison to the rest of the country where PSA testing was not freely available . However, in 2009 two large, randomized, prospective studies attempted to answer this decade-long question: The Prostate, Lung, Colorectal and Ovarian Cancer screening trial (PLCO) from the United States which showed no benefit to screening 7, , and the European Randomized Trial of Screening for Prostate Cancer (ERSPC) which reported a 20% reduction in mortality from PCa, but at the expense of 1,410 men having to undergo screening and additional 48 men to undergo treatment in order to save 1 life . The latter results implied a significant overtreatment and overdiagnosis of clinically insignificant cancers as a result of screening. Although survival rates after radical management of localized PCa are high, the risk of complications including urinary, sexual, and bowel dysfunction is not negligible 12, . Based on these findings, the United States Preventive Services Task Force (USPSTF) after careful review and balance of the risks and benefits – mainly, problems of overdiagnosis and over-treatment – recommended against a population-based screening program . The rationale for screening after inconsistent results from these two large, randomized trials coupled with the inherent PCa treatment complications (including urinary, sexual, and bowel dysfunction) created a conflicting and confusing environment for the world-wide treating physicians and their patients. While many questions still remain unanswered, PSA (although an imperfect test) continues to be the only tool we currently have available to identify patients at higher risk of dying from PCa. Adaption of new risk stratification strategies may be the solution to minimize patient harms and offset the risk/benefit ratio. In this report we provide evidence in support of early and targeted screening, earlier termination of screening, and prolongation of the screening interval to every 2–4 years.