Recommendations

Revised 18 May 2012

  • The Genitourinary Cancer Tumour Group (GUTG) of the BC Cancer Agency and the Vancouver Prostate Centre (VPC) recommend that asymptomatic men 50-55 years of age or older, with an estimated life expectancy of more than 10 years, who are well informed about the risks of over-diagnosis and over-treatment, consider PSA testing for the early diagnosis of prostate cancer.
  • The GUTG and VPC do not support unselected, population-wide PSA screening because of the potential for over-diagnosis, over-treatment and detriment to quality adjusted survival.

1. The decision to use PSA testing for the early detection of prostate cancer should be individualized. Patients should be informed of the known risks and the potential benefits PSA testing.

  • Men need to be informed of the risks and benefits of testing before it is undertaken. The risks of over-detection, over-treatment and active surveillance as a treatment option should be included in this discussion.
  • The following is a brief summary of risks and benefits of early detection of prostate cancer. (Recommended reading [10])

Risks of PSA testing and Early Detection of Prostate Cancer

  • False negative and false positive PSA results
    • A low PSA test does not mean that a person does not have prostate cancer, and a high PSA does not necessarily mean a person does have prostate cancer.
  • Biopsy
    • Pain and very rarely infection.
  • Distress and anxiety
    • Being diagnosed with prostate cancer is associated with anxiety.
  • Over-diagnosis and treatment
    • Over-diagnosis refers to the detection of cancers that would not otherwise have become clinically apparent. This could result in treatment of a prostate cancer that may not have been a problem for a man in his lifetime
    • The risks of treatment such as radiation and surgery include urinary problems and incontinence, sexual dysfunction, and bowel problems.

Benefits of PSA testing and Early Detection of Prostate Cancer

  • Early detection of prostate cancer can save lives.
    • From what we know so far, at its best, 293 men need to be screened and 12 diagnosed with prostate cancer to prevent 1 death over a 14 year period.
  • Early detection and treatment of prostate cancer can avert future prostate cancer-related problems.

2. Early detection and risk assessment of prostate cancer should be offered to asymptomatic men 50-55 years of age or older with an estimated life expectancy of more than 10 years who wish to be screened.

  • Early detection begins at age 50 years for men at average risk of prostate cancer and should generally cease when life expectancy falls below 10 years. The optimal starting age and frequency of PSA testing is not known. The recent studies performed PSA testing every 2 to 4 years. The most cost-effective and evidence-based strategy is for PSA testing every 4 years from age 55 to 70 years.
  • Men with higher risk for prostate cancer should consider testing at age 40 to 45 (African American origin, family history of prostate cancer, BRCA1 or BRCA2 mutation carrier). Individual risk can be assessed by the use of a risk calculator e.g. http://www.prostatecancer-riskcalulator.com/

3. Abnormal results trigger referral to urologists.

  • Men with a PSA of >3.0 μg/L should be referred to a urologist for consideration of biopsy. A PSA that is > 2.0 but increasing by more than 0.75-1.0 μg/L/year should also be referred.
  • Men with an abnormal digital rectal examination should also be referred to a urologist regardless of the PSA value.
  • Any subsequent decision to recommend biopsy needs to include consideration of life expectancy, co-morbidities, prostate co-conditions (e.g. large BPH, prostatitis), PSA velocity, DRE findings, and patient risk factors and preference.

4. Treatment Guidelines for PSA-detected Cancer.

  • Early detection of prostate cancer should be linked to a treatment algorithm that includes discussion and prioritization of active surveillance for appropriate candidates with low risk prostate cancer. [11]
  • Active surveillance in men with very low and low risk cancers, and some older men with intermediate risk cancer should be carried out in a programmatic manner, as coordinated by a Urologist or Oncologist following established guidelines. .
  • Men with intermediate risk, high risk localized and other cancers should be treated as per current guidelines [12]