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Risk stratification in prostate cancer screening

Nature Reviews Urology volume 10, pages 38–48 (2013)Cite this article

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A Correction to this article was published on 23 April 2013

This article has been updated

Abstract

Screening for prostate cancer is a controversial topic within the field of urology. The US Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial did not demonstrate any difference in prostate-cancer-related mortality rates between men screened annually rather than on an 'opportunistic' basis. However, in the world's largest trial to date—the European Randomised Study of Screening for Prostate Cancer—screening every 2–4 years was associated with a 21% reduction in prostate-cancer-related mortality rate after 11 years. Citing the uncertain ratio between potential harm and potential benefit, the US Preventive Services Task Force recently recommended against serum PSA screening. Although this ratio has yet to be elucidated, PSA testing—and early tumour detection—is undoubtedly beneficial for some individuals. Instead of adopting a 'one size fits all' approach, physicians are likely to perform personalized risk assessment to minimize the risk of negative consequences, such as anxiety, unnecessary testing and biopsies, overdiagnosis, and overtreatment. The PSA test needs to be combined with other predictive factors or be used in a more thoughtful way to identify men at risk of symptomatic or life-threatening cancer, without overdiagnosing indolent disease. A risk-adapted approach is needed, whereby PSA testing is tailored to individual risk.

Key Points

  • Data regarding the potential effect of PSA-based screening on disease-specific mortality rates are promising, but not yet sufficient to support definite conclusions

  • Screening for prostate cancer should focus on the detection of high-risk and potentially life-threatening disease

  • Prostate cancer screening guidelines vary between different countries, medical organizations, and guideline groups; however, there is general agreement that screening should be preceded by a discussion about risks and benefits

  • Elevated PSA and abnormal digital rectal examination (DRE)—routine tests in prostate cancer screening—demonstrate poor performance characteristics; carefully selected combinations of other currently available tests could improve diagnostic accuracy

  • Multivariate risk prediction tools outperform PSA testing and DRE in terms of predicting biopsy outcome; however, most of these tools lack calibration and external validation

  • Individualized screening is perhaps the most ethical approach to screening, but requires both physicians and patients to be adequately well informed

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Figure 1: PSA course over time in men with prostate cancer and BPH.

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Change history

  • 23 April 2013

    In the version of this article initially published online and in print, descriptions of intact free PSA and nicked PSA are incorrect. The error has been corrected for the HTML and PDF versions of the article.

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Acknowledgements

S. V. Carlsson is supported by funding from the Swedish Cancer Society, the Swedish Society for Medical Research, the Sweden-America Foundation, and the Swedish Council for Working Life and Social Research. M. J. Roobol is supported by the Dutch Cancer Society and the Prostate Cancer Research Foundation Rotterdam (SWOP). The authors would like to thank Dr Stacy Loeb for independent review of the final manuscript before submission.

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Authors and Affiliations

  1. Department of Urology, Erasmus Medical Center, Rotterdam, 3000 CA, Netherlands

    Monique J. Roobol

  2. Department of Surgery (Urology Service), Memorial Sloan-Kettering Cancer Center, New York, 10065, NY, USA

    Sigrid V. Carlsson

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  1. Monique J. Roobol
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M. J. Roobol and S. V. Carlsson contributed equally to this work and independently performed literature searches and reviews. Both authors wrote separate draft versions of the manuscript that were subsequently merged into one. Both authors then edited the article and approved the final manuscript prior to submission.

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Correspondence to Monique J. Roobol.

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Roobol, M., Carlsson, S. Risk stratification in prostate cancer screening. Nat Rev Urol 10, 38–48 (2013). https://doi.org/10.1038/nrurol.2012.225

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