Enhancements Of Psa Tests To Increase Specificity
Because elevated PSA levels can be caused by conditions other than PCa, enhancements have been sought to increase the specificity of PSA testing:
PSA Velocity correlates with both PCa risk and aggressiveness but is confounded by BPH and by prostatitis, and its short-term utility is limited because of the time required to determine whether PSA increases persist., In men without PCa, PSA velocity increases by ~0.15 ng/mL/year versus ~0.350.40 ng/mL/year with PCa.,, The natural history of PSAV in PCa patients is that PSA increases by 2% per year prior to a change point when increases accelerate. After this, PSA increases by 15% in patients presenting with localized disease and 63% in those presenting with metastases. Usually, the change point occurs at PSA levels below 4.0 ng/mL, and the median age at the change point is 57 years old, occurring in the 40s in many patients. PSA velocities > 2.0 ng/mL/year not caused by prostatitis may reflect incurable PCa.,
PSAV Risk Count quantifies the persistence of PSA increases over time, i.e., the number of times the PSAV increases by a specific amount, such as 0.2 or 0.4 ng/mL/year. Unless a long PSA history is available, PSAV risk count also is limited by the time required to obtain a valid result.,
Weighing Your Options For Treatment
If you test positive for prostate cancer, you have some options as to what youd like to do about it. Until recently, nearly everyone opted for surgery or radiation, while some patients choose not to undergo treatment, instead opting for active surveillance, during which the cancers are left alone but regularly monitored to be certain that theyre not growing.
Certainly, screening can lead to earlier prostate cancer detection, and with earlier detection, youre eligible for multiple different treatments or active surveillance, said Sia Daneshmand, MD, associate professor of urology at Keck School of Medicine of USC and director of urologic oncology at the USC Institute of Urology at Keck Medicine of USC. So we encourage patients who are candidates for screening to discuss it with their urologist and/or primary care physician so that we can determine whats the best course of treatment for them.
There also is a new option for those seeking prostate cancer treatment. Its called High-Intensity Focused Ultrasound , which uses ultrasound beams to non-surgically destroy prostate tumors.
If you are in the Los Angeles area, schedule an appointment with one of our urologists by calling or by visiting Urology.KeckMedicine.org/request-an-appointment.
Response To Public Comment
A draft version of this recommendation statement was posted for public comment on the USPSTF website from April 11 to May 8, 2017. A number of comments suggested that because men are now living longer, they should be screened beyond 70 years of age. However, the USPSTF considered other evidence in addition to data on life expectancy when recommending against screening in men older than 70 years, including results from large screening trials that did not report a mortality benefit for men older than 70 years and evidence on the increased likelihood of harm from screening, diagnostic evaluation, treatment, overdiagnosis, and overtreatment. Several comments requested a recommendation for younger men and for baseline PSA-based screening in men 40 years and older or 50 years and older. The USPSTF found inadequate evidence that screening younger men or performing baseline PSA-based screening provides benefit.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Authors followed the policy regarding conflicts of interest described at . All members of the USPSTF receive travel reimbursement and an honorarium for participating in USPSTF meetings.
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What Are The Signs And Symptoms Of Prostate Cancer
Early prostate cancer usually causes no symptoms. That is why starting these screening tests early is so important.
More advanced prostate cancer can cause symptoms, such as:
- Trouble urinating
- Trouble with getting an erection
- Pain in other areas of the body from cancer that has spread to the bones
We cannot rely on the development of symptoms and complaints, because its just too late. We want to catch prostate cancer before it causes any symptoms. We have to start PSA testing, MRI scans of the prostate and other ways of testing and screening for prostate cancer early in the game.
Benefits And Risks Of Screenings
The benefit of any cancer screening test is to find cancer early, when it easier to treat. But the value of PSA screening for prostate cancer is debated. No single answer fits all men.
Prostate cancer often grows very slowly. PSA levels can begin to rise years before a cancer causes any symptoms or problems. It is also very common as men age. In many cases, the cancer will not cause any problems or shorten a mans life span.
For these reasons, it is not clear if the benefits of routine screenings outweigh the risks or side effects of being treated for prostate cancer once it is found.
There are other factors to think about before having a PSA test:
- Anxiety. Elevated PSA levels does not always mean you have cancer. These results and the need for further testing can cause a lot of fear and anxiety, even if you do not have prostate cancer.
- Side effects from further testing. If your PSA test is higher than normal, you may need to have a one or more biopsies to find out for sure. A biopsy is safe, but can cause problems such as an infection, pain, fever, or blood in the semen or urine.
- Overtreatment. Many prostate cancers will not affect your normal life span. But since it is impossible to know for sure, most people want to get treatment. Cancer treatment can have serious side effects, including problems with erections and urinating. These side effects can cause more problems than the untreated cancer.
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When Should You Start Screening
First, talk to your doctor at your next checkup to go over your particular risk factors. You may have more than one risk factor at play and thus have a greater chance of developing prostate cancer than other men.
In general, discussions with your doctor about screening for prostate cancer should begin in your 40s. Here are some rough guidelines:
|Do you have family history of prostate,ovarian, breast, colon, or pancreatic cancers,or do you know that gene mutations are present in your family?||Discuss screening with your doctor startingaround age 40.|
Should You Know Your Psa Level
Instead of a national screening programme, there is an informed choice programme, called prostate cancer risk management, for healthy men aged 50 or over who ask their GP about PSA testing. It aims to give men good information on the pros and cons of a PSA test.
If you’re a man aged 50 or over and decide to have your PSA levels tested after talking to your GP, they can arrange for it to be carried out free on the NHS.
If results show you have a raised level of PSA, your GP may suggest further tests.
What Do The Results Mean
PSA levels may be above the baseline for various reasons other than prostate cancer.
Other factors that can raise PSA levels include:
- older age
- an enlarged prostate â because of benign prostatic hyperplasia , for example
- prostatitis, which is inflammation and swelling of the prostate
Also, people with obesity may have lower PSA readings.
In addition, some medications may reduce PSA levels, including:
- 5-alpha reductase inhibitors, which can help treat BPH
- aspirin, which some people take regularly as a blood thinner
- statins, which help manage cholesterol levels
- thiazide diuretics, a kind of water pill that can help reduce high blood pressure
Some herbal medicines and supplements can also lower PSA levels. Tell the doctor about any medications and supplements before undergoing the test.
High PSA levels alone do not indicate cancer. However, if a DRE also reveals changes, a doctor may recommend a biopsy for a more accurate result.
The PCA3 is another test for prostate cancer that doctors use in some circumstances. Find out more.
The Psa Prohibition Era
In the aftermath of the USPSTFs 2008 and 2012 grade D recommendations, PSA testing declined in the U.S. by 2530%, significantly reducing overall PCa incidence rates and precluding early PCa detection in many patients. Beginning with the 2008 recommendation, in men over age 75, there has been a reversal of the favorable tumor stage migration, and since 2011, among men 75 years old, there has been a significant increase in the proportion and the absolute number of men presenting with metastases at the time of diagnosis with a similar trend in younger men. CISNET has projected that if screening had been completely phased out in 2012, as recommended by the USPSTF, the number of cases of distant-stage disease would return to the pre-PSA screening era levels by the year 2025. Empirically, in the Göteborg screening trial, 9 years after the termination of PSA testing, the incidence of potentially lethal cancers was the same as that of non-screened men.,
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Summary Of Recommendations And Evidence
For men aged 55 to 69 years, the decision to undergo periodic prostate-specific antigen based screening for prostate cancer should be an individual one. Before deciding whether to be screened, men should have an opportunity to discuss the potential benefits and harms of screening with their clinician and to incorporate their values and preferences in the decision. Screening offers a small potential benefit of reducing the chance of death from prostate cancer in some men. However, many men will experience potential harms of screening, including false-positive results that require additional testing and possible prostate biopsy overdiagnosis and overtreatment and treatment complications, such as incontinence and erectile dysfunction. In determining whether this service is appropriate in individual cases, patients and clinicians should consider the balance of benefits and harms on the basis of family history, race/ethnicity, comorbid medical conditions, patient values about the benefits and harms of screening and treatment-specific outcomes, and other health needs. Clinicians should not screen men who do not express a preference for screening . C recommendation.
Screening for Prostate Cancer: Clinical Summary of the USPSTF Recommendations
Note: For a summary of the evidence systematically reviewed in making this recommendation, the full recommendation statement, and supporting documents, go to .
Harms Of Early Detection And Treatment
The harms of screening for prostate cancer include harms from the PSA screening test and subsequent harms from diagnosis and treatment. Potential harms of screening include frequent false-positive results and psychological harms. One major trial in men screened every 2 to 4 years concluded that, over 10 years, more than 15% of men experienced at least 1 false-positive test result.5 Harms of diagnostic procedures include complications of prostate biopsy, such as pain, hematospermia , and infection. Approximately 1% of prostate biopsies result in complications requiring hospitalization. The false-positive and complication rates from biopsy are higher in older men.3 Adequate evidence suggests that the harms of screening and diagnostic procedures are at least small.
PSA-based screening for prostate cancer leads to the diagnosis of prostate cancer in some men whose cancer would never have become symptomatic during their lifetime. Treatment of these men results in harms and provides them with no benefit. This is known as overdiagnosis, and follow-up of large randomized trials suggests that 20% to 50% of men diagnosed with prostate cancer through screening may be overdiagnosed.3 Overdiagnosis rates would be expected to increase with age and to be highest in men 70 years and older because older men have high risk of death from competing causes.
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What Happens During A Prostate Exam
Screening for prostate cancer typically involves two types of investigation: a digital rectal exam and a prostate-specific antigen test. Your doctor may advise having both or just one.
These investigations will show your doctor if there are any abnormalities in your prostate. Abnormalities dont always mean cancer, and neither of these tests can tell you definitively if you have prostate cancer. But they are an important step in picking up prostate cancer because they show whether further investigations are needed.
The only way to know for sure whether you have cancer is to have a biopsy of the prostate.
When To Startand Stopscreening
The doctors and researchers who recommend screening argue that cases of prostate cancer found very early can be cured more quickly, with less chance of relapse or spread. Those who recommend against routine screening point to the slow-moving nature of prostate cancer and the side effects of surgical and medical treatment, which can be considerable.
The introduction of PSA screening in the US led to an initial increase in the number of prostate cancer cases diagnosed each year, even though many of these new cases were non-aggressive or low-risk prostate cancer. The issue was not that screening was harmful, it was that many of these low-risk cancers did not necessarily need immediate treatment. It seems strange to say that a patient might be better off leaving cancer untreated, but in some cases, it can be true. For a few years, the United States Preventative Services Task Force recommended against PSA screening. We are now seeing more cases of advanced prostate cancer diagnosed in recent years. This may be a long-tail effect of that USPSTF recommendation. It has now been changed to note that for men aged 55 to 69 years, the decision to undergo PSA screening is an individual one and should be discussed with your doctor. USPSTF continues to recommend against screening for men aged 70 and over.
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Health & Wellnessal Roker Reveals Prostate Cancer Diagnosis
Rettig said that someone who has a “strong family history” of early onset prostate cancer might want to talk to their primary care provider or other health care practitioner earlier in life, while someone with less risk might prefer to wait.
The guidelines for how often men should be screened again also vary. If you have a high prostate-specific antigen , a protein made by cells in the prostate gland, you may be recommended to come back for more frequent screenings, but those with lower PSA levels might only be advised to come back every four years or so.
“If you’re 55 and have you have a PSA of less than one, you can wait four years to get screened again,” Rettig explained. “Alternatively, if you’re 45 and have a PSA of two and a half, that might be someone who might get a biopsy or be re-screened within the year. … How frequently one would be prescreened is really contingent upon the specifics of the patient.”
Craig Melvin And Al Roker Premiere ‘get Checked’ Psa
Dr. Matthew Rettig, the medical director of the Prostate Cancer Program at the Institute of Urologic Oncology at UCLA in California, said that even if screenings aren’t performed right away, men should at least start talking about them with their doctors early in life.
“I think I would have that conversation fairly early on in life, maybe even in 30s or 40s, about when to initiate screening,” said Retting. “I think that would be most important for patients who are at high risk for prostate cancer and high risk for early onset of prostate cancer. Those are the types of patients that probably ought to have the discussion and make a decision about when to start screening at a relatively young age.”
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Criticisms Of Uspstf Analysis
The USPSTF overstepped its mandate by superimposing the harms of treatment upon those of testing and diagnosis. The USPSTF placed screening in a context that would be applied across the population, which underestimates benefits and overestimates harms with reasonable use in appropriate candidates. It incorrectly assumed that every man with abnormal screening results would undergo biopsy and that all men diagnosed with PCa would undergo definitive treatment.
RCTs conducted over a short time period do not reveal accurate estimates of the absolute benefits of screening over a lifetime. There is a delay from the start of a RCT until a screening-induced mortality reduction can be attained, and early data underestimates benefits and exaggerates harms.
The most important criticism of the USPSTF methodology is its heavy weighting of PLCO results in which it was only later revealed that nearly 90% of controls had PSA testing before or during the trial. In arriving at its grade D recommendation, the USPSTF relied on the incorrectly-reported ~50% rate of PSA testing in the control arm in the 2009 PLCO report,
approximately 50% of men in the control group received at least 1 PSA test during the study
In contrast, in a 2016 independent evaluation of the PLCO data, Shoag, et al reported,
the proportion of control participants who reported having undergone at least 1 PSA test before or during the trial was close to 90%.
Research Into Prostate Cancer Screening
Many prostate cancers grow very slowly and dont cause men any problems in their lifetime. Overall, evidence from trials of prostate screening has shown that prostate cancer screening does not reduce the number of men dying from prostate cancer.
The Cancer Research UK CAP trial looked at whether a single PSA blood test would reduce the number of men dying of prostate cancer. This was a large UK study with over 400,000 men between the ages of 50 and 69 taking part. Around half the men were offered a PSA blood test the other half weren’t.
The results in early 2018 showed that the number of men dying from prostate cancer was the same in both groups. This was after 10 years of follow up. The researchers say that this trial doesnt support PSA testing as a screening test for prostate cancer. They say we need more research to find a better screening test.
This supports what the 2013 Cochrane review found. This looked at screening research from a number of trials and concluded that prostate cancer screening did not reduce the number of men dying from prostate cancer.
Research looking at doing more than one test doesnt show that this would help either. Increasing the number of tests could increase the level of harms such as diagnosing those cancers that wouldnt cause any harm . Many men have side effects from treatment and the risks of routine PSA screening outweigh the benefits.
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