Editing AUA: Early Detection of Prostate Cancer (2023) (section)

== PSA screening ==

* '''When considering people for whom prostate cancer screening would be appropriate, use shared-decision making (SDM) and proceed based on a person’s values and preferences.'''
**The use of publicly available decision aids may be helpful in SDM, where available, and are updated to the most current level of evidence.

=== Tests to use in prostate cancer screening ===
*'''<span style="color:#ff0000">Use PSA as the first screening test</span>'''
** '''<span style="color:#ff0000">Digital rectal exam (DRE)</span>'''
***'''<span style="color:#ff0000">Clinicians should not use DRE as the sole screening method.</span>'''
****'''The primary screening modality recommended for the early detection of prostate cancer is a PSA blood test.''' 
*** '''<span style="color:#ff0000">Insufficient evidence to support adding DRE to PSA-based prostate cancer screening.</span>'''
**** For various reasons, clinicians may choose to complement PSA screening with DRE based on SDM.
**'''Stockholm-3 (STHLM-3)'''
***Multiplex test combining 
****Clinical variables (age, first-degree family history of prostate cancer, and previous biopsy)
****Blood biomarkers (total PSA, free PSA, ratio of free to total PSA, hK2, MIC-1, and MSMB)
****Polygenic risk score (PRS)
***Has been evaluated as a first-line screening test for predicting the risk of GG2+ prostate cancers.[https://pubmed.ncbi.nlm.nih.gov/26563502/]
****STHLM-3 found to have a higher predictive accuracy compared to PSA alone (area under the curve [AUC] 0.74 versus 0.56) and reduced unnecessary biopsies by 32%
****Further validation in diverse populations to confirm these findings will be necessary to move forward into practice.
** '''Polygenic risk score (PRS)''' 
***Genetic tests used to predict a person’s risk of developing prostate cancer.
***Typically constructed as the weighted sum of a collection of genetic variants, usually single nucleotide polymorphisms (SNPs) defined as single base-pair variations from the reference genome[https://pubmed.ncbi.nlm.nih.gov/35251129/] 
***Little evidence to mandate which SNP panel or PRS to use and where to threshold risk to create strata with different screening intensities.
***At the time of evidence review, no PRS tool has been shown to discriminate between aggressive and indolent prostate cancer risk

=== Age to start prostate cancer screening ===
*'''If age < 40, PSA screening is NOT recommended'''
*'''<span style="color:#ff0000">If age > 40 and < 45</span>'''
**'''<span style="color:#ff0000">Offer screening if at increased risk of developing prostate cancer based on (3):</span>'''
**#'''<span style="color:#ff0000">Black ancestry</span>'''
**#'''<span style="color:#ff0000">Germline mutations</span>'''
**#'''<span style="color:#ff0000">"Strong" family history of prostate cancer</span>''' 
*'''<span style="color:#ff0000">If age >45-50, may begin prostate cancer screening and offer a baseline PSA test</span>'''
**Change from 2018 guidelines which recommended screening if age 55-69
***The 2023 guidelines describe that earlier initiation of screening is supported by observational studies that have demonstrated a prognostic value of obtaining a baseline PSA in early midlife
***The randomized trials that demonstrate a benefit for prostate cancer screening (Goteborg-1 and ERSPC) began at ages 50 and 55 years, respectively.
**No randomized evidence showing a benefit to initiation of routine screening for prostate cancer before 45 years of age.

=== Frequency of prostate cancer screening/discontinuing screening ===
*'''<span style="color:#ff0000">Offer regular prostate cancer screening every 2 to 4 years to people aged 50 to 69 years.</span>'''
* '''<span style="color:#ff0000">May personalize the re-screening interval, or decide to discontinue screening, following SDM, based on</span>''' 
**'''<span style="color:#ff0000">Prostate cancer risk</span>'''
***'''<span style="color:#ff0000">If at increased risk of developing prostate cancer, based on Black ancestry, germline mutations, or strong family history, consider screening more frequently</span>'''
**'''<span style="color:#ff0000">PSA</span>'''
***'''<span style="color:#ff0000">If age 45-70 and</span>''' 
****'''<span style="color:#ff0000">PSA 1-3 ng/mL, re-screening interval can be 1-4 years</span>'''
****'''<span style="color:#ff0000">PSA < 1 ng/mL, re-screening interval can be prolonged</span>'''
***'''If age 60 and PSA < 1 ng/mL (age-specific median), reasonable to significantly lengthen the re-screening interval or discontinue screening, based on SDM, provided there are no other risk factors, such as strong family history of prostate cancer'''
***The Panel notes most studies regarding baseline PSA have been conducted in populations of primarily White patients. 
****The Southern Community Cohort Study (100% Black patients) showed that PSA levels in midlife were similar to those among White controls in prior studies and were strongly associated with risk of aggressive prostate cancer.
**'''<span style="color:#ff0000">Age</span>'''
***'''<span style="color:#ff0000">If age age ≥75  and PSA is < 3 ng/mL, may discontinue or substantially lengthen the re-screening interval for patients.</span>'''
**'''<span style="color:#ff0000">Life expectancy</span>'''
***'''<span style="color:#ff0000">In select patients who are very healthy with an estimated life expectancy of at ≥10 years, ongoing screening every 2-4 years is reasonable</span>'''
*** '''<span style="color:#ff0000">For patients with < 10 year estimated life expectancy, screening is not likely to provide a benefit in terms of disease-specific or overall mortality.</span>'''
****Based on current Social Security Administration (SSA) data, American men older than 77 years of age have less than a 10-year life expectancy.
*** '''<span style="color:#ff0000">Risk calculators have been developed to estimate a patient’s life expectancy</span>'''
**** For the purpose of estimating life expectancy, the use of these tools is likely more reliable than individual clinician judgment.
****Life expectancy risk calculators
*****[https://www.ssa.gov/oact/population/longevity.html US Social Security Administration]
*****[https://webcore.mskcc.org/survey/surveyform.aspx?preview=true&excelsurveylistid=4 Memorial Sloan Ketettering Cancer Center Male Life Expectancy Survey]
*****[http://cambridgeprognosticgroup.com/notloggedin.php Cambridge Prognostic Groups]
**'''General health'''
**'''Patient preference'''