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=== Magnetic imaging ===
=== Magnetic imaging ===
If a high PSA level is obtained then MRI imaging is used and detects significant prostate cancer with up to 97% accuracy and allows the targeting of biopsy needles into the region of interest. This model potentially minimizes unnecessary prostate biopsies while maximizing biopsy yield.<ref>{{cite web|url=http://sperlingprostatecenter.com/multiparametric-mri-detectiondiagnosis-superior-trus-biopsy/|title=Multiparametric mri detection/diagnosis is superior to TRUS biopsy.|last1=Sperling|first1=D.|website=Sperling Prostate Center|accessdate=11 March 2016}}</ref> Despite concerns about the cost of MRI scans, compared to the long-term cost burden of the PSA/TRUS biopsy-based standard of care, the imaging model has been found to be cost-effective.<ref>{{cite journal | vauthors = de Rooij M, Crienen S, Witjes JA, Barentsz JO, Rovers MM, Grutters JP | title = Cost-effectiveness of magnetic resonance (MR) imaging and MR-guided targeted biopsy versus systematic transrectal ultrasound-guided biopsy in diagnosing prostate cancer: a modelling study from a health care perspective | journal = European Urology | volume = 66 | issue = 3 | pages = 430–6 | date = September 2014 | pmid = 24377803 | doi = 10.1016/j.eururo.2013.12.012 }}</ref>
If a high PSA level is obtained then MRI imaging is used and detects significant prostate cancer with up to 97% accuracy and allows the targeting of biopsy needles into the region of interest. This model potentially minimizes unnecessary prostate biopsies while maximizing biopsy yield.{{dubious}}{{cn}} Despite concerns about the cost of MRI scans, compared to the long-term cost burden of the PSA/TRUS biopsy-based standard of care, the imaging model has been found to be cost-effective.{{dubious}}{{cn}}


=== Other imaging ===
=== Other imaging ===

Revision as of 11:06, 3 March 2018

Prostate cancer screening

Prostate cancer screening is testing done to try to detect undiagnosed prostate cancer in those without symptoms.[1][2] It is not clear whether early detection reduces mortality rates.[2] When abnormal prostate tissue or cancer is found early, it may be easier to treat and cure.

Screening for prostate cancer may include the use of the digital rectal examination (DRE), during which the prostate is assessed manually through the wall of the rectum or the measurement of prostate-specific antigen (PSA) in the blood. The evidence remains insufficient to determine whether screening with prostate-specific antigen (PSA) or digital rectal exam (DRE) reduces mortality from prostate cancer.[1] A 2013 Cochrane review concluded it results in "no statistically significant difference in prostate cancer-specific mortality between men randomized to the screening and control groups." The American studies were determined to have a high bias. European studies included in this review were of low bias and one reported "a significant reduction in prostate cancer-specific mortality." PSA screening with DRE was not assessed in this review. DRE was not assessed separately.[3] Others recommend screening with a PSA test or DRE who are at high risk and anticipate a long life expectancy.[4] Guidelines from the American Urological Association,[5] and the American Cancer Society[6] recommend that men be informed of the risks and benefits of screening. The American Society of Clinical Oncology recommends screening be discouraged in those who are expected to live less than ten years, while in those with a life expectancy of greater than ten years a decision should be made by the person in question based on the potential risks and benefits. In general, they conclude that based on recent research, "it is uncertain whether the benefits associated with PSA testing for prostate cancer screening are worth the harms associated with screening and subsequent unnecessary treatment."[7]

Prostate biopsies are used to diagnose prostate cancer but are not done on asymptomatic men and therefore are not used for screening. Biopsies of prostate cancer are the gold standard in detecting prostate cancer.[8][9] Infections sometimes develop after prostate biopsy.[10] Prostate biopsy guided by magnetic resonance imaging has improved the diagnostic accuracy of the procedure.[11][12]

Prostate-specific antigen

Prostate-specific antigen

Prostate-specific antigen (PSA) is secreted by the epithelial cells of the prostate gland and can be detected in a sample of blood.[13] PSA is present in small quantities in the serum of men with healthy prostates, but is often elevated in the presence of prostate cancer or other prostate disorders.[14] PSA is not a unique indicator of prostate cancer, but may also detect prostatitis or benign prostatic hyperplasia.[15]

The United States Preventive Services Task Force (USPSTF) has reversed their complete opposition to PCa screening.[16] A 2018 review states, "In the aftermath of the USPSTF recommendations, the widespread rejection of screening by many primary care physicians has had far-reaching consequences, notably, a reversion to more PCa cases being high-grade and advanced at diagnosis."[16] The review further states, "The USPSTF has now issued a revised draft recommendation, suggesting shared decision making for screening healthy men 55 years to 69 years of age."[16]

PSA testing of men in their mid-70s and older, is discouraged as most people at this age diagnosed with prostate cancer detected by a PSA test would die of other causes before the cancer caused problems.[17] On the other hand, up to 25% of men diagnosed in their 70s or even 80s die of prostate cancer, if they have high-grade (i.e., aggressive) prostate cancer.[18] Conversely, some argue against PSA testing for men who are too young, because too many men would have to be screened to find one cancer, and too many men would have treatment for cancer that would not progress. Low-risk prostate cancer does not always require immediate treatment, but may be amenable to active surveillance.[19] A PSA test cannot 'prove' the existence prostate cancer by itself. Varying levels of the antigen can be due to other causes.[20]

Digital examination

Older studies describe the manual detection of prostate asymmetry and nodules combined with biopsies to detect tumors. In some studies, subsequent detection of lymph node metastases were found in a small number of those examined.[21][2] If a digital exam suggests anomalies, a PSA screening is then performed. If an elevated PSA level is found, a digital exam is then performed.[2]

Additional diagnostic tools

Biopsy

Prostate biopsies are considered the gold standard in detecting prostate cancer.[8][9] Infection is a possible risk.[10] MRI guided techniques has improved the diagnostic accuracy of the procedure.[11][12] Biopsies can be done through the rectum or penis.

Ultrasound

Transrectal ultrasonography (TRUS) has the advantage of being fast with minimal invasive and better than MRI for the evaluation of superficial tumor.[2] It also gives details about the layers of the rectal wall, accurate and useful for staging primary rectal cancer. While MRI is better in visualization of locally advanced and stenosing cancers. For staging perirectal lymph nodes, both TRUS and MRI are capable. TRUS has small field of view, but 3D TRUS can improve the diagnosis of anorectal diseases.[22]

Magnetic imaging

If a high PSA level is obtained then MRI imaging is used and detects significant prostate cancer with up to 97% accuracy and allows the targeting of biopsy needles into the region of interest. This model potentially minimizes unnecessary prostate biopsies while maximizing biopsy yield.[dubious – discuss][citation needed] Despite concerns about the cost of MRI scans, compared to the long-term cost burden of the PSA/TRUS biopsy-based standard of care, the imaging model has been found to be cost-effective.[dubious – discuss][citation needed]

Other imaging

68Ga-PSMA PET/CT imaging has become in a relatively short period of time, the gold standard for restaging recurrent prostate cancer in clinical centers in which this imaging modality is available.[23] It is likely to become the standard imaging modality in the staging of intermediate-to-high risk primary prostate cancer.[23] The potential to guide therapy, and to facilitate more accurate prostatic biopsy is being explored.[23] In the theranostic paradigm, 68Ga-PSMA PET/CT imaging is critical for detecting prostate specific membrane antigen-avid disease which may then respond to targeted 177Lu-PSMA or 225Ac-PSMA therapies.[23] For local recurrence, 68Ga-PSMA PET/MR or PET/CT in combination with mpMR is most appropriate.[24]

Other

  • The four-kallikrein panel (4Kscore) is another test available.[25]
  • The Prostate Health Index (PHI) is another test available.[25]
  • Prostate cancer antigen 3 (PCA3) is a is another test available.[25]

Guidelines

  • In 2012 the United States Preventive Services Task Force (USPSTF) recommended against prostate cancer screening using PSA.[26] As of 2018 a draft for new recommendations suggests that screening be individualized for those between the ages of 55 to 69. It notes a small potential decrease in the risk of dying from prostate cancer but harm from overtreatment.[27] In those over the age of 70 PSA based screening is still recommended against.[27]
  • American Cancer Society "recommends that asymptomatic men who have at least a 10-year life expectancy have an opportunity to make an informed decision with their health care provider about screening for prostate cancer after they receive information about the uncertainties, risks, and potential benefits associated with prostate cancer screening. Prostate cancer screening should not occur without an informed decision-making process. Men at average risk should receive this information beginning at age 50 years. Men in higher risk groups should receive this information before age 50 years. Men should either receive this information directly from their health care providers or be referred to reliable and culturally appropriate sources."[28]
  • Some U.S. radiation oncologists and medical oncologists who specialize in treating prostate cancer recommend obtaining a baseline PSA in all men at age 35[29] or beginning annual PSA testing in high risk men at age 35.[30]
  • The American Urological Association Patient Guide to Prostate Cancer. The American Urological Association said in early 2009 that "The decision to screen is one that a man should make in conjunction with his physician, and should incorporate known prostate cancer risk factors, such as family history of prostate cancer, age, ethnicity/race, and whether or not a man has had a previous negative prostate biopsy. These factors are different for every man and, therefore, the benefits of screening should be considered in the broader perspective."[31] [32]
  • As of 2018, the UK National Health Service did not offer general PSA screening, for similar reasons to those given above. Individual patients who request it can normally obtain a test.[20]
  • The Canadian Urological Association suggests that men age 45 who have a higher chance of developing of prostate cancer should be screened for the disease.[25]

Controversy

Screening for prostate cancer continues to generate debate by clinicians and broader lay audiences. Publications authored by governmental, non-governmental and medical organizations continue ongoing discussions and recommendations for screening.[3] One in six men will be diagnosed with prostate cancer during their lifetime but many concerns exist concerning the overdiagnosis and overtreatment of prostate cancer based upon screening results.[33][34] Prostate cancer, along with melanoma and leukemia, is often diagnosed in an outpatient setting. Though the death rates from prostate cancer continue to decline, 238,590 men were diagnosed with prostate cancer in 2013 while 29,720 died as a result. Death rates from prostate cancer have declined at a steady rate since 1992. Cancers of the prostate, lung and bronchus, and colorectum account for about 50% of all newly diagnosed cancers in men. Prostate cancer alone constitutes 28% cases in men. Screening for prostate cancer varies by state and indicates differences in the use of screening for prostate cancer as well as variations in its occurrence. Out all cases of prostate cancer, African american men have an incidence of 62%. African American men are less likely to receive standard therapy for prostate cancer therapies and this may indicate that if they were to receive higher quality cancer treatment their survival rates would be similar to whites.[33] Prostate cancer is also extremely heterogeneous: many, perhaps most, prostate cancers are indolent and would never progress to a clinically meaningful stage if left undiagnosed and untreated during a man's lifetime. On the other hand, a subset are potentially lethal, and screening can identify some of these within a window of opportunity for cure[35] Thus the concept of PSA screening is advocated by some[36] as a means of detecting high-risk, potentially lethal prostate cancer, with the understanding that lower-risk disease, if discovered, often does not need treatment and may be amenable to active surveillance.[37]

Screening for prostate cancer is controversial because of cost and uncertain long-term benefits to patients.[38] Horan echos that sentiment in his book.[39]

Private medical institutes, such as the Mayo Clinic, likewise acknowledge that "organizations vary in their recommendations about who should — and who shouldn't — get a PSA screening test. They conclude: "Ultimately, whether you should have a PSA test is something you'll have to decide after discussing it with your doctor, considering your risk factors and weighing your personal preferences."[40]

A study in Europe resulted in only a small decline in death rates and concluded that 48 men would need to be treated to save one life. But of the 47 men who were treated, most would be unable to ever again function sexually and require more frequent trips to the bathroom.[39] Aggressive marketing of screening tests by drug companies has also generated controversy as has the advocacy of testing by the American Urological Association.[39]

One commentator has observed: “[I]t is prudent only to use a single PSA determination as a baseline, with biopsy and cancer treatment reserved for those with significant PSA changes over time, or for those with clinical manifestations mandating immediate therapy..... absolute levels of PSA are rarely meaningful; it is the relative change in PSA levels over time that provides insight, but not definitive proof of a cancerous condition necessitating therapy.“[41]

History

Global comparisons of prostate cancer screening

As early as the 1990s, prostate screening of PSA was done. In the European Randomized Study of Screening for Prostate Cancer (ERSPC) initiated in the early 1990s, the researchers concluded that PSA-based screening did reduce the rate of death from prostate cancer but instead created a high risk of overdiagnosis, i.e., 1410 men would need to be screened and 48 additional cases of prostate cancer would need to be treated to prevent just one death from prostate cancer within 9 years.[42]

A study published in the European Journal of Cancer (October 2009) documented that prostate cancer screening reduced prostate cancer mortality by 37 percent. By utilizing a control group of men from Northern Ireland, where PSA screening is infrequent, the research showed this substantial reduction in prostate cancer deaths when compared to men who were PSA tested as part of the ERSPC study.[43]

A study published in the New England Journal of Medicine in 2009, found that over a 7 to 10-year period, "screening did not reduce the death rate in men 55 and over."[39] Former screening proponents, including some from Stanford University, have come out against routine testing. In February 2010, the American Cancer Society urged "more caution in using the test." And the American College of Preventive Medicine concluded that "there was insufficient evidence to recommend routine screening."[39]

A further study, the NHS Comparison Arm for ProtecT (CAP) as part of the Prostate testing for cancer and Treatment (ProtecT) study randomized GP practices with 460,000 men aged 50–69 at centers in 9 cities in Britain from 2001-2005 to usual care or prostate cancer screening with PSA (biopsy if PSA ≥ 3).df.[44] The "Comparison Arm" has yet to report as of early 2018.[45]

See also

References

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  28. ^ Wolf, A. M. D.; Wender, R. C.; Etzioni, R. B.; Thompson, I. M.; D'Amico, A. V.; Volk, R. J.; Brooks, D. D.; Dash, C.; Guessous, I. "American Cancer Society Guideline for the Early Detection of Prostate Cancer: Update 2010". CA: A Cancer Journal for Clinicians. 60 (2): 70–98. doi:10.3322/caac.20066.
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  42. ^ Schröder FH, Hugosson J, Roobol MJ, Tammela TL, Ciatto S, Nelen V, Kwiatkowski M, Lujan M, Lilja H, Zappa M, Denis LJ, Recker F, Berenguer A, Määttänen L, Bangma CH, Aus G, Villers A, Rebillard X, van der Kwast T, Blijenberg BG, Moss SM, de Koning HJ, Auvinen A (March 2009). "Screening and prostate-cancer mortality in a randomized European study". The New England Journal of Medicine. 360 (13): 1320–8. doi:10.1056/NEJMoa0810084. PMID 19297566.
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    ISRCTN (March 6, 2006). "The CAP (Comparison Arm for ProtecT) study". isrctn.org.
    ISRCTN (November 19, 2007). "The ProtecT trial". isrctn.org.
  45. ^ "Outline of the ProtecT study and its data and samples", on the study website at Bristol University.
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