The Memorial Sloan Kettering Cancer Center Recommendations for Prostate Cancer Screening

Abstract

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.

Screening for Prostate Cancer Starting at Age 50–54 Years. A Population-based Cohort Study

“…We would first note that the overall strategy in Göteborg –screening every two years, median starting age in the mid-fifties[7] – is closer to current US and European guidelines[2-5] than the ERSPC as a whole (median starting age in the early sixties, screening every four years)[19]. As we have argued previously [27], the Göteborg trial would underestimate the mortality benefits of screening due to sub-optimal methods of detection (e.g.…”

What's new in screening in 2015?

“…[53] Long-term data from the Malmö Preventive Project suggests that men aged 60 with a PSA level < 1.0 ng/ml can possibly refrain from further testing. [7, 54, 55]…”

“…Such approaches includes better stratifying baseline risk and adapting re-screening intervals according to a man’s age, general health and PSA level[7] as well as using multivariable approaches to help biopsy decision-making including reflex biomarkers[6] or risk calculators[15]. MRI is also emerging as a potentially promising tool in the pre-diagnostic setting as well as to guide targeted biopsies.…”

Prostate Cancer Screening: A Brief Tool to Incorporate Patient Preferences in a Clinical Encounter

“…Risk of prostate cancer is predicted by PSA level (25) with recent recommendations suggesting different approaches to men using PSA cut off levels of <1, 1–3, and >3 ng/ml (26). …”