MSKCC updates recommendations on risk-based prostate cancer screening

In an article currently in press in Urology (“the Gold journal”) researchers and clinicians at the Memorial Sloan-Kettering Cancer Center have provided a detailed 2016 update to the MSKCC guidelines on the use of the PSA test in assessment of risk for prostate cancer.

The article by Vickers et al. is complemented by a “Beyond the Abstract” Q&A discussion between Vickers and UroToday that can be found on the UroToday web site.

The new MSKCC recommendations on prostate cancer screening have been developed in response to three limitations of previous screening guidelines:

  • An insufficient evidence base
  • A failure to link screening with treatment, and
  • A lack of risk stratification.

The objective of the revised MSKCC guidance is to offer “a schema” for prostate cancer screening that maximizes the benefits, in terms of reduction in prostate cancer-specific mortality, and minimizes the harms, in terms of over-diagnosis and over-treatment.

The revised, detailed guidance is also available on the MSKCC web site. The basic schema now being proposed by MSKCC — for men who choose to be screened following informed decision-making — is as follows:

  • Starting at age 45, a PSA test without any digital rectal examination.
  • If the patient’s initial PSA level is ≥ 3 ng/ml, a prostate biopsy should be considered.
  • If the patient’s initial PSA level is ≥ 1 but < 3 ng/ml, he should return for PSA testing every 2 to 4 years.
  • If the patient’s initial PSA level is < 1 ng/mL, he should return for PSA testing at 6 to 10 years.
  • PSA testing should end
    • At age 60 for men with a PSA level that is still ≤ 1 ng/ml
    • At age 70, unless a man is very healthy and has a higher than average PSA level
    • At age 75 for all men

The decision whether or not to biopsy a man with a PSA > 3 ng/ml should be based on a variety of factors, including

  • A repeat blood draw for confirmatory testing of the PSA level
  • The results of a digital rectal examination
  • Work-up for the presence of benign disease.

Additional reflex tests in blood such as a free-to-total PSA ratio, the Prostate Health Index, or 4KScore, or urinary testing of PCA3, can also be informative for some patients.

The authors conclude by stating that

The best evidence suggests that more restricted indication for prostate biopsy and a more focused approach to pursue screening in men at highest risk of lethal cancer would retain most of the mortality benefits of aggressive screening schema, while importantly reducing harms from over-detection and over-treatment.

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