“There may be a cancer subject that is more controversial than the screening and early detection of prostate cancer, but I don't know what that is,” said Peter H. Carroll, MD, MPH, Professor and Chair, Department of Urology, UCSF Helen Diller Family Comprehensive Cancer Center, speaking at the NCCN 23rd Annual Conference. Dr. Carroll, Chair of the NCCN Guidelines for Prostate Cancer Early Detection, reviewed updates to the 2018 guidelines.
Screening/early detection guidelines for prostate cancer from NCCN, American Urological Association (AUA), American Cancer Society (ACS), and the US Preventive Services Task Force (USPSTF) differ in several ways, but these guidelines are coming closer to agreement, and in 2018, they all support shared decision-making between patients and clinicians.
The 2018 NCCN Guidelines for Prostate Cancer Early Detection continue to support early detection in well-informed healthy men and to recommend beginning baseline screening at 45 years of age, which is younger than the recommendations set forth in the other 3 sets of guidelines. These updated NCCN Guidelines also support germline testing, consistent with other NCCN Guidelines.
“The NCCN Guidelines acknowledge that the optimal screening of high-risk patients is not completely known,” Dr. Carroll stated.
A key feature of the updated guidelines is that they provide alternatives to routine biopsy in men with elevated prostate-specific antigen (PSA) levels, such as serum biomarker testing and parametric MRI. Further, they support the use of active surveillance in men identified to have low-risk cancers, linked to and compliant with the NCCN Guidelines for Prostate Cancer.
Dr. Carroll acknowledged that in the 1990s and 2000s, routine screening was poorly implemented, with downsides that included overscreening of older men, underscreening of younger men, overtreatment of low-risk disease, and undertreatment of high-risk disease. “Despite driving mortality down by >50%, the cost of routine screening was too much in entirely avoidable treatment and its attendant side effects,” he stated. “We need to screen smarter. The issue is not whether PSA testing and screening save lives,” he stated.
NCCN, AUA, ACS, and USPSTF recommend different target ages for screening, populations to test, and thresholds for biopsy. NCCN recommends PSA screening for all men aged 45 to 75 years and discourages screening in patients aged >75 years; biopsy is recommended when the PSA level is >3.0 ng/mL. The USPSTF has changed its controversial recommendation against routine PSA screening for all men. The new recommendation proposes individualized screening decisions based on consultation with a clinician, considering risks versus benefits and personal preferences (ie, shared decision-making). NCCN, AUA, and ACS guidelines also incorporate shared decision-making.
Vickers AJ, Edwards K, Cooperberg MR, Mushlin AI. A simple schema for informed decision making about prostate cancer screening. Ann Intern Med 2014;161:441–442.
Pritchard CC, Mateo J, Walsh MF. Inherited DNA-repair gene mutations in men with metastatic prostate cancer. N Engl J Med 2016;375:443–453.
Dong Z, Wang H, Xu M. Intermittent hormone therapy versus continuous hormone therapy for locally advanced prostate cancer: a meta-analysis. Aging Male 2015;18:233–237.
Smith MR, Saad F, Chowdhury S. Apalutamide treatment and metastasis-free survival in prostate cancer. N Engl J Med 2018;378:1408–1418.