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June 2009: Prostate Cancer Screening – 2009 Best Practice Guidelines

01 Jun 2009

Dr. Kevin C. Zorn completed his fellowship in minimally invasive surgery at the University of Chicago Medical Center. He is board-certified by the Royal College of Physicians and Surgeons of Canada and board-eligible for the American Board of Urology. He is an expert in performing robotic prostate surgery.

 

Kevin C. Zorn, MDCM, FRCSC
Assistant Professor of Surgery
Associate Residency Program Director
Co-Director of the University of Chicago
Minimally Invasive Urology Fellowship
Phone: (773) 564-5385

 

Prostate cancer is the most common non-cutaneous cancer in men in the United States. Despite its prevalence, the natural history of this disease is remarkably varied. In many patients, the cancer progresses slowly, resulting in tumors that remain localized to the prostate gland. Although potentially life-threatening, such cancers are most often curable. Many patients with low-grade and volume cancers may be candidates for active surveillance.

In other patients, however, tumor growth may be more rapid, resulting in cancer spreading beyond the confines of the prostate. In such cases, long-term survival may be considerably diminished compared to survival associated with organ-confined cancers. Strategies for managing prostate cancer have therefore been aimed at early detection, with selective, tailored treatment.

Prostate-specific antigen (PSA) is a tumor marker currently used for early detection of prostate cancer. Measurement of serum PSA levels has significant clinical application in other areas of prostate disease management. Following is current information about the use of PSA for:

  1. The evaluation of men at risk for prostate cancer
  2. The risks and benefits of early detection
  3. Assistance in pre-treatment staging or risk assessment
  4. Post-treatment monitoring
  5. Use as a guide in management of men who recur after primary or secondary therapy

At this year’s annual American Urological Association (AUA) meeting, held in Chicago IL, updated best practice guidelines were released for prostate cancer screening. Compared to the 2000 AUA guidelines, there are two notable differences in the current policy.

First, the age for obtaining a baseline PSA has been lowered to 40 years. Second, the current policy no longer recommends a single, threshold value of PSA which should prompt prostate biopsy. Rather, the decision to proceed to prostate biopsy should be based primarily on PSA and Digital Rectal Exam (DRE) 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 co-morbidities. So while the AUA guidelines call for screenings to begin at a younger age, they express an individualized assessment and approach for proceeding with prostate biopsies.

 

The guidelines come following the release of two recent landmark studies published in the New England Journal of Medicine on the role of PSA screening for prostate cancer. 1,2

Based on a randomized trial of prostate cancer screening of 182,000 European men over a nine year period, there appears to be a modest 20 percent reduction in prostate cancer mortality among those screened when compared to those that are not.1 In another screening study of 76,693 American men, there was no statistically significant difference in prostate cancer mortality when comparing men that were and were not screened.2

Despite the issue of short follow-up and contamination of the control group actually receiving PSA screening in up to 52 percent of men, the data suggests there is a large amount of over-diagnosis and over-treatment associated with prostate cancer screening. Unfortunately, at this point it is not possible to state that screening is associated with more benefit than harm.

As such, early detection and risk assessment of prostate cancer should be offered to asymptomatic men 40 years of age or older who wish to be screened with an estimated life expectancy of more than 10 years.

A copy of the new best-practice guidelines is available online: (http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines/main-reports/psa09.pdf)

For more information about the prostate and prostate cancer screenings visit Robotic Prostate Surgery, or call (773) 564-5385 to schedule an appointment.


References

1. Schroder, F.H., Hugosson, J., Roobol, M.J., et al. Screening and prostate-cancer mortality in a randomized European study. N Engl J Med, 360: 11320-8, 2009
2. Andriole, G.L., Grubb, R.L., Buys, S.S., et al. Mortality results from a randomized prostate cancer screening trial. N Engl J Med, 360: 1310-19, 2009