Guidelines likely to advise PSA test at age 40

Baseline prostate-specific antigen screening for men at age 40, replacement of a specific PSA cutoff value with “a continuum of risk assessment,” and a new emphasis on tracking changes in PSA over time are among possible updates to guidelines expected soon from the American Urological Association.

Advances in understanding of the relationship between PSA levels and prostate cancer risk prompted the 2008 update to the American Urological Association (AUA) PSA Best Practice Guideline. Although the update had not been finalized at press time, provided a preview of likely changes during the annual meeting of the American Urological Association.

The current recommendation is to begin PSA screening at age 50, as specified in the existing guidelines, which were last updated in 2000. They are now considering a screening at age 40.

The 2000 guidelines recommended screening African men at a younger age because of their higher risk. The authors of the update devised a table to help physicians manage higher-risk patients, based on factors such as race and age.

In addition, studies published in the literature up to 2007 indicate that prostate density may play a bigger role in diagnosis than prostate volume, and this is likely to be reflected in the guidelines as well, the Urology faculty at the University of California, San Francisco said.

The cutoff PSA value of 4 ng/mL cited in the 2000 guidelines may be abolished in favor of a “continuum of risk with no safe or normal value of PSA. The AUA will likely recommend consideration of many factors rather than one threshold value.

The committee may recommend that physicians track not only how PSA values change over time but also how quickly they change, based on the idea that PSA behavior may be a better indicator of risk than a fixed cutoff value.

As with most guidelines panels, they will likely not recommend screening men with less than 10 years of lifetime left.

Prostate cancer mortality has declined since the institution of PSA screening. Even though, such screening may facilitate detection of earlier stage disease. “PSA screening remains extremely controversial. Critics state that overdiagnosis leads to overtreatment of indolent disease.

There is no level 1 evidence about PSA screening. Two ongoing studies will address this. Until then, guidelines are based on available evidence.

The American Urological Association guideline committee reviewed all PSA-related articles in the literature from 1999 to 2007 and then selected the most relevant articles.

It is still out of peer review and not yet approved. The guidelines are coming soon.