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The case for Prostate-Specific Antigen (PSA)
Screening starting at age 40
Newswise — Dr. Robert Nadler,
of Northwestern University, wrote an
excellent editorial in a recent issue of
Cancer regarding the commencement of
prostate cancer (CaP) screening at age 40.
The National Comprehensive
Cancer Care Network (NCCN) recommends an
initial PSA at age 40 for men of all races.
The frequency of subsequent
PSA tests would depend on the initial level.
Dr Nadler refers to work by Scales and
associates that analyzed data from the 2002
Behavioral Risk Factor Surveillance System.
This database is an annual,
population-based survey from the Centers for
Disease Control that determines the rate of
screening in men between the ages of 40 and
50 years.
It reports that 22.5% of men
ages 40-49 had a PSA test the previous year,
compared to 53.7% of men older than 50
years. More African-American men than
Caucasian men were screened (33.6% vs.
21.5%).
Nadler believes the data is
encouraging in light of the fact that most
primary care physicians are not aware of
guidelines to screen men at age 40. He
points out that a baseline PSA at age 40
serves as a starting point for determining
risk.
For example, the median PSA
level for men in their 40’s is 0.7ng/ml and
for men in their 50’s it is 0.9ng/ml. An
age-specific median PSA between 0.7 or 0.9
and 2.5ng.ml results in a 14.6-fold and
7.6-fold increased risk of developing CaP
for men in their 40’s and 50’s,
respectively.
Carter reported that men with
a PSA velocity of 0.35ng/ml/year or greater
were 5 times more likely to die of CaP more
than 10 years later. Thus, a baseline PSA at
age 40 serves as a starting point for
determining PSA velocity and detecting CaP
in young men at risk.
Nadler suggests that to be
effective, PSA needs to be measured yearly
beginning at age 40, while the NCCN
guidelines recommend if the initial PSA is
0.6ng/ml or less, it can next be rechecked
at age 45.
Men with a PSA of 4.0ng/ml or
higher who undergo radical prostatectomy
have a 30% chance of positive surgical
margins and thus worse outcomes.
Decreasing the PSA threshold
for biopsy and treatment to 2.0 or 2.5ng/ml
would decrease this risk, Nadler writes.
Finally, he pointed out that
the death rate from CaP in the US has
decreased from 41,800 in 1997 to 27,050 in
2007.
Yet the position that small
cancers are unnecessarily treated remains a
counterargument. For these men, a diagnosis
does not mandate immediate treatment and
active surveillance with expectant
management can be appropriate.
He supports the
counterargument with the issues of cost and
complications of the biopsy procedure, not
to mention the psychological burden of a
cancer diagnosis.
Yet, in conclusion, the
guidelines and rationale for CaP screening
beginning at age 40 are well presented by
Dr. Nadler, and serve as important
information for urologists and primary care
physicians.
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