Relative Value of Race, Family History and Prostate Specific Antigen as Indications for Early Initiation of Prostate Cancer Screening

Vertosick, Emily; Poon, Bing Ying; Vickers, Andrew J.

doi:10.1016/j.juro.2014.03.032

Cited by 39 publications

(26 citation statements)

References 20 publications

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“…Our view is that although age 55 – 69 was the “core group” of the ERSPC, the Göteborg Randomized Screening Study 22 included men aged 50 – 64, clearly giving randomized support for starting screening at 50. As regards earlier screening for men at increased risk, we have demonstrated unequivocally that PSA is a far stronger risk factor than either race or family history 23 . Hence, our guidelines do not suggest differential PSA screening for African Americans.…”

Section: Discussionmentioning

confidence: 77%

The Memorial Sloan Kettering Cancer Center Recommendations for Prostate Cancer Screening

Vickers

Eastham

Scardino

et al. 2016

Urology

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The Memorial Sloan-Kettering Cancer Center (MSKCC) recommendations on prostate cancer screening were developed in response to three limitations of previous screening guidelines: insufficient evidence-base, failure to link screening with treatment, and lack of risk stratification. The objective of the recommendations is to provide 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 overdiagnosis and overtreatment. We recommend the following schema for men choosing to be screened following informed decision-making. Starting at age 45, PSA without DRE. If PSA ≥ 3 ng / mL: consider prostate biopsy; PSA ≥ 1 but < 3 ng / mL: return for PSA testing every 2 – 4 years; PSA < 1 ng / mL: return for PSA testing at 6–10 years. PSA testing should end at age 60 for men with PSA ≤ 1 ng/ mL; at 70, unless a man is very healthy and has a higher than average PSA; at 75 for all men. The decision to biopsy a man with a PSA > 3 ng / mL should be based on a variety of factors including repeat blood draw for confirmatory testing of the PSA level, DRE results, and work-up for 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 in some patients. 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 overdetection and overtreatment.

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Section: Discussionmentioning

confidence: 77%

The Memorial Sloan Kettering Cancer Center Recommendations for Prostate Cancer Screening

Vickers

Eastham

Scardino

et al. 2016

Urology

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“…Risk stratification contributed by PSA was far greater than that reported for other risk factors such as race or family history [17]. Among men with modestly elevated PSA at age 50 or 60, the four KLK panel yielded C-indexes from 0.82 to 0.88 for the prediction of documented distant metastasis.…”

Section: Discussionmentioning

confidence: 93%

Improving the Specificity of Screening for Lethal Prostate Cancer Using Prostate-specific Antigen and a Panel of Kallikrein Markers: A Nested Case–Control Study

et al. 2015

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Background A disadvantage of prostate-specific antigen (PSA) for the early detection of prostate cancer (PCa) is that many men must be screened, biopsied, and diagnosed to prevent one death. Objective To increase the specificity of screening for lethal PCa at an early stage. Design, setting, and participants We conducted a case–control study nested within a population-based cohort. PSA and three additional kallikreins were measured in cryopreserved blood from a population-based cohort in Västerbotten, Sweden. Of 40 379 men providing blood at ages 40, 50, and 60 yr from 1986 to 2009, 12 561 men were followed for >15 yr. From this cohort, the Swedish Cancer Registry identified 1423 incident PCa cases, 235 with distant metastasis. Outcome measurements and statistical analysis Risk of distant metastasis for different PSA levels and a prespecified statistical model based on the four kallikrein markers. Results and limitations Most metastatic cases occurred in men with PSA in the top quartile at age 50 yr (69%) or 60 yr (74%), whereas 20-yr risk of metastasis for men with PSA below median was low (≤0.6%). Among men with PSA >2 ng/ml, a prespecified model based on four kallikrein markers significantly enhanced the prediction of metastasis compared with PSA alone. About half of all men with PSA >2 ng/ml were defined as low risk by this model and had a ≤1% 15-yr risk of metastasis. Conclusions Screening at ages 50–60 yr should focus on men with PSA in the top quartile. A marker panel can aid biopsy decision making. Patient summary For men in their fifties, screening should focus on those in the top 10% of PSA scores because close to half of subsequent cases of distant metastasis are found in this group. Testing of four kallikrein markers in men with an elevated PSA could aid biopsy decision making.

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“…Caucasian men[27]. A strategy where men are stratified based on a baseline PSA value, and actively offered screening within the highest 10% of PSA was shown to produce a better risk-to-benefit ratio as compared to stratifying men based on race or family history of PC[28]. Once screening starts, optimizing the harm-to-benefit ratio is crucial and this could be done using a multivariable approach, including all available relevant information.…”

Section: Methodsmentioning

confidence: 99%

“…The role of family history of PC was examined within the PLCO trial (predominantly white men) whereby the authors suggest that men with a positive family history should be screened yearly with both DRE and PSA. [100] However, accumulating evidence, including data from the Korean heart study[101], BLSA and Malmö studies, now suggests that the baseline PSA level in midlife is a stronger predictor of a future diagnosis of lethal PC than both family history[28, 102] and race[28], which begs the question: why not obtain a baseline PSA to stratify risk in all men early in life? Vertosick and Vickers argue that “if a recommendation is made to screen early in men at high risk, a baseline PSA measurement at age 45 years would be a better method to identify men at high risk than family history or race”.…”

Section: Methodsmentioning

confidence: 99%

What's new in screening in 2015?

Carlsson

Roobol

2016

Current Opinion in Urology

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Purpose of review The aim of this review was to highlight important articles in the field of prostate cancer (PC) screening published during 2015 and early 2016. Four major areas were identified: 1. screening strategies; 2. post USPSTF 2011–2012; 3. screening trends/patterns; and 4. shared decision making (SDM). Recent findings Several studies furthered the evidence that screening reduces the risk of metastasis and death from PC. Multiplex screening strategies are of proven benefit; genetics and MRI need further evaluation. PSA screening rates declined in men above age 50 as did the overall PC incidence following the USPSTF 2011–2012 recommendation against PSA. The consequences of declining screening rates will become apparent in the next few years. More research is needed to identify the most optimal approach to engage in, and implement, effective SDM in clinical practice. Summary Data emerging in 2015 provided evidence on the question of how best to screen and brought more steps in the right direction of “next-generation PC screening”. Screening is ongoing in all men regardless of whether they might benefit from early detection and treatment or not. After the USPSTF 2011–2012 recommendation the rates of PSA testing are declining, however this decline is observed in all men and not solely in those who will not benefit. The long-term effect of this recommendation might not be as anticipated. More studies are needed on how to implement the best available evidence on who, and when, to screen into clinical practice.

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Relative Value of Race, Family History and Prostate Specific Antigen as Indications for Early Initiation of Prostate Cancer Screening

Cited by 39 publications

References 20 publications

The Memorial Sloan Kettering Cancer Center Recommendations for Prostate Cancer Screening

The Memorial Sloan Kettering Cancer Center Recommendations for Prostate Cancer Screening

Improving the Specificity of Screening for Lethal Prostate Cancer Using Prostate-specific Antigen and a Panel of Kallikrein Markers: A Nested Case–Control Study

What's new in screening in 2015?

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