PSA testing and patients at risk: the NCCN speaks

The National Comprehensive Cancer Network (NCCN) has just issued revised guidance on early detection of prostate cancer. The revised guidelines take account of the results of the recent ERSPC and PLCO trials that assessed the benefit of PSA screening. The NCCN Guidelines contend that PSA testing does save lives when performed intelligently in men at high-risk of developing the disease.

In a detailed media release, NCCN has laid out an argument based on the concept that PSA testing is effective and needs to be more rigorously conducted in high-risk populations. The full text of the revised guidance is also available on the NCCN web site. (You do need to register to be able to read this document, but there is no cost involved.) To quote Mark Kawasaki, MD, the chairman of the guidelines committee, “We are most likely to produce further declines in prostate cancer mortality if we focus on younger men who are more likely to die of prostate cancer than other causes and the diagnosing of aggressive prostate cancer in all men.”

This is an opinion that correlates precisely with the position taken by America’s Prostate Cancer Organizations in a statement made earlier this year, when we stated that, “Despite recent data and media coverage about PSA testing and prostate cancer mortality, the early detection and appropriate treatment of clinically significant prostate cancer remains a critical priority, especially among men at high risk because of family history, ethnicity, or other factors that define such risk.”

The following quotations are taken directly from the NCCN’s media release:

  • “Some of the controversy with the recent trials assessing the benefits of PSA testing stems from people confusing early detection with screening…. It is imperative to distinguish the two terms from each other and understand that screening implies testing a random group of participants where as early detection targets a select group of patients whose need is greatest.”
  • “It is important to note that the NCCN Guidelines for Prostate Cancer Early Detection are for the purpose of detecting cancer early in high-risk men, not the screening of mass populations.”
  • “… the current NCCN Guidelines recommend that at age 40, high-risk men be offered a baseline PSA and DRE and if their PSA is 1.0 ng/mL or greater, that they receive annual follow-ups. If their PSA is less than 1.0, the NCCN Guidelines recommend that these men be screened again at age 45.”
  • “NCCN Guideline Panel Members acknowledge that there is no ‘right’ answer about PSA testing for everyone, but that each man needs to make an informed decision with his physician.”

The “New” Prostate Cancer InfoLink congratulates the NCCN Guideline Panel members for generating an important and helpful new guidance document for physicians and their patients that may assist everyone to be clearer about the continued importance of prostate cancer testing using the PSA test in men who have reason to be concerned about their risk for this disease.

10 Responses

  1. Halleluja! At long last someone has tried to distinguish between diagnostic testing and wholesale screening in he US. That has been the position in Australia for some time now.

  2. I hate to be sarcastic, but give these guys a great big “duh” to go along with that applause. Mike, you know what I have been saying all along. Studies that eliminate the below 50 group are truly missing a huge opportunity in this fight. Pretty much muttering things up, I say.

  3. Are men in Australia being counseled on the potential ravages of prostate cancer? Being informed and making one’s own decision is the key and that’s what the new report concludes. Hence I would conclude from the new report that ALL men need to have the key discussion outlined in the new report (and not duck out of serious decision making if they are only of “normal” risk). Unfortunately too many men, if they are like I was, will simply use these reports to stick their heads in the sand and not seriously contemplate their options.

    So what is needed is wholesale education and wholesale decision making on the part of men and their significant others (who will also “suffer” if aggressive prostate cancer strikes their loved one)

  4. Tony: It’s not “these guys” fault that studies designed back in the mid to late 1980s didn’t include men under 50. We are trying to change the direction of an aircraft carrier. It takes time and patience!


  5. There has never been a movement for “mass screening” in the USA. It has been rather difficult to provide consistent information for men at risk. These guidelines for physicians and patients alike are about early detection and prevention of an advanced disease diagnosis. Let’s take the overdiagnosis potential down to a minimum and identify those that continue to be diagnosed with significant disease. Urology as the front line specialty charged with identifying the disease should observe these guidelines to the letter … no excuses.

  6. I recommend reading the NCCN guidelines as well as the American Urological Association guidelines. I think you will find that you can substantially reduce your risk of invasive prostate cancer by obtaining a PSA test and following up with biopsy if so indicated. To ignore the very meaningful information a PSA test (with full analysis as per NCCN describes) can provide is akin to ignoring the warning on cigarette boxes, not wearing a seatbelt, crossing the street on red lights, etc. Stupid things you can easily avoid, just as the PSA test is very easy to get. It must of course then be interpreted by appropriate follow-up in order to avoid both over-treatment and under-treatment.

  7. Aloha,

    From my own experience, it is still very difficult to identify that group of men that should be tested. I do not recall any relatives that had prostate cancer. For as long as I can remember, my DRE was normal, even when prostate cancer was detected.

    It is also very important to identify those men with prostate cancer that will react badly to the recommended treatments.


  8. I don’t really understand the “high risk” criteria. Certainly the higher one’s risk the more diligent one ought to be, but all men are at risk. If some men have higher risk how much higher? 50% more, 100% more. Is PSA testing more effective per se if you are at higher risk. I would propose that PSA testing is equally effective for all men — it can lead to diagnosis and help make decisions re further steps. So if a man is more likely to have prostate cancer, definitely test, but the test and follow ups are just as important no matter what the a priori risk. Once the diagnosis is made, you have entered a new risk group — even if you didn’t know it before! And not knowing that you are at risk doesn’t mean you aren’t at risk — screening, followed by biopsy if indicated, can help you evaluate your risk. No screening will give you no information!

  9. PSA testing for men has its advantages and its disadvantages. It has been found that when men undergo PSA testing to avert prostate cancer, nearly 50 men have to go undergo treatments which are not needed and a some of these men face grave troubles with the treatment. So one should take proper care and should have knowledge on it.

  10. Jimmy: So the issue is why do the 50 men have to undergo treatment. Are you including biopsy as treatment? Getting the full array of PSA analysis (PSA velocity, density, free PSA, etc.) and after biopsy and Gleason score, amount uncovered, etc., one can get a more reasonable estimate of the likelihood of invasive cancer in the future (or already) and then begin to decide on whether to undergo treatment.

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