Examining the Efficacy of Screening with Prostate-Specific Antigen Testing in Reducing Prostate Cancer Mortality

Prostate cancer is a prevalent, worldwide problem among male adults. This literature review, “Examining the Efficacy of Screening with Prostate-Specific Antigen Testing in Reducing Prostate Cancer Mortality,” focuses on a safe and effective screening test for detecting prostate cancer in its early stages—prostate-specific antigen testing—and seeks to answer the clinical question, “Does screening with PSA testing for the early detection of prostate cancer in males ages 50-80 years significantly reduce prostate cancer mortality?” A literature search of peer-reviewed articles within the last fifteen years on databases such as CINAHL and Pub Med was conducted to find five articles that pertained to the clinical question. An analysis and synthesis of the research articles provided promising yet not conclusive evidence that prostate-specific antigen testing significantly reduces the absolute risk of prostate cancer morality. Further research is needed to provide more substantial evidence to support the use of prostate-specific antigen testing in clinical practice

Prostate-specific antigen testing accuracy in community practice

BACKGROUND: Most data on prostate-specific antigen (PSA) testing come from urologic cohorts comprised of volunteers for screening programs. We evaluated the diagnostic accuracy of PSA testing for detecting prostate cancer in community practice. METHODS: PSA testing results were compared with a reference standard of prostate biopsy. Subjects were 2,620 men 40 years and older undergoing (PSA) testing and biopsy from 1/1/95 through 12/31/98 in the Albuquerque, New Mexico metropolitan area. Diagnostic measures included the area under the receiver-operating characteristic curve, sensitivity, specificity, and likelihood ratios. RESULTS: Cancer was detected in 930 subjects (35%). The area under the ROC curve was 0.67 and the PSA cutpoint of 4 ng/ml had a sensitivity of 86% and a specificity of 33%. The likelihood ratio for a positive test (LR+) was 1.28 and 0.42 for a negative test (LR-). PSA testing was most sensitive (90%) but least specific (27%) in older men. Age-specific reference ranges improved specificity in older men (49%) but decreased sensitivity (70%), with an LR+ of 1.38. Lowering the PSA cutpoint to 2 ng/ml resulted in a sensitivity of 95%, a specificity of 20%, and an LR+ of 1.19. CONCLUSIONS: PSA testing had fair discriminating power for detecting prostate cancer in community practice. The PSA cutpoint of 4 ng/ml was sensitive but relatively non-specific and associated likelihood ratios only moderately revised probabilities for cancer. Using age-specific reference ranges and a PSA cutpoint below 4 ng/ml improved test specificity and sensitivity, respectively, but did not improve the overall accuracy of PSA testing

Estimate of Opportunistic Prostate Specific Antigen Testing in the Finnish Randomized Study of Screening for Prostate Cancer

Purpose: Screening for prostate cancer remains controversial, although ERSPC (European Randomized Study of Screening for Prostate Cancer) showed a 21% relative reduction in prostate cancer mortality. The Finnish Randomized Study of Screening for Prostate Cancer, which is the largest component of ERSPC, demonstrated a statistically nonsignificant 16% mortality benefit in a separate analysis. The purpose of this study was to estimate the degree of contamination in the control arm of the Finnish trial. Materials and Methods: Altogether 48,295 and 31,872 men were randomized to the control and screening arms, respectively. The screening period was 1996 to 2007. The extent of prostate specific antigen testing was analyzed retrospectively using laboratory databases. The incidence of T1c prostate cancer (impalpable prostate cancer detected by elevated prostate specific antigen) was determined from the national Finnish Cancer Registry. Results: Approximately 1.4% of men had undergone prostate specific antigen testing 1 to 3 years before randomization. By the first 4, 8 and 12 years of follow-up 18.1%, 47.7% and 62.7% of men in the control arm had undergone prostate specific antigen testing at least once and in the screening arm the proportions were 69.8%, 81.1% and 85.2%, respectively. The cumulative incidence of T1c prostate cancer was 6.1% in the screening arm and 4.5% in the control arm (RR 1.21, 95% CI 1.13-1.30). Conclusions: A large proportion of men in the control arm had undergone a prostate specific antigen test during the 15-year followup. Contamination is likely to dilute differences in prostate cancer mortality between the arms in the Finnish screening trial.Peer reviewe

The end of the road for prostate specific antigen testing?

Many candidate biomarkers for diagnosis of prostate cancer have been investigated, but prostate‑specific antigen (PSA) testing remains the frontline test for both mass screening and individual clinical testing. Although the PSA test is cost‑effective, analytically reliable, and flexibly high throughput, it has a very weak correlation with prostate malignancy. This has resulted in over‑diagnosis and over‑treatment of patients leading to costly economic, social, and psychological impacts. PSA testing lacks the ability to molecularly characterize prostate diseases and define aggressiveness and lethality, which are necessary to influence choice of treatment. Therefore, newer molecular tests are beginning to replace the PSA tests. The prostate cancer antigen 3 test has shown superiority and is now widely used. The recently reported sarcosine urine test, the already delineated TMPRSS2: ETS fusion genes, the glutathione‑S‑transferase P1 serum marker, and enhancer of zeste homolog 2 biomarker may also help improve diagnosis and prognostication of prostate cancer. The analytical trend is toward a multiplex testing format using molecular and/or proteomic techniques that are reliable, accurate, reproducible, and ensure rapid quantitation. Therefore, validation of these newer biomarkers and their assays are necessary for both large‑scale clinical trials and clinical utility.Keywords: Prostate cancer and prostate cancer antigen 3, prostate cancer antigen 3, prostate specific antigen, sarcosineNigerian Journal of Clinical Practice • Oct-Dec 2013 • Vol 16 • Issue

Use of Prostate-specific Antigen Testing in Medicare Beneficiaries: Association with Previous Evaluation

Objective: Determine uptake of prostate-specific antigen (PSA) testing in Medicare beneficiaries according to previous receipt of PSA testing. Methods: A 5% random sample of men aged 67 years or older without a previous diagnosis of prostate cancer was identified through 2009-2012 Medicare claims. We measured the annualized frequency of PSA screening among men due for PSA testing, stratified by PSA testing use in the previous 2 years, and clustered by ordering provider. Results: Throughout the study period, PSA testing use was consistently higher for men with previous screening than for men without previous screening. For men without previous screening, there was a decline in testing that was most pronounced in 2012. Compared with 2009, the corresponding odds ratios were 0.98 [95% confidence interval (CI) (0.96-1.00)] in 2010, 0.94 [95% CI (0.92-0.95)] in 2011, and 0.66 [95% CI (0.65-0.68)] in 2012. In contrast, for men with previous screening, PSA testing frequency was stable from 2009 to 2011, and declined to a lesser extent in 2012 [odds ratio 0.80, 95% CI (0.79-0.81)]. Conclusion: Receipt of PSA testing is highly dependent on whether an individual was tested in the recent past. In previously unscreened men, the largest decrease occurred in 2012, which may reflect in part the publication of US Preventive Services Task Force guidelines, but there was much less impact among men already being screened. © 2017 Family Medicine and Community Health

Modalities of prostate specific antigen testing in Gauteng clinics and hospitals, South Africa

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfilment of the requirements for the degree in Master of Medicine (Chemical Pathology). Johannesburg, 2018.Background: The use of prostate specific antigen (PSA) in screening for prostate cancer remains controversial. However, in developing countries mortality from prostate cancer remains high due to lack of screening facilities such as PSA testing. Prostate specific antigen testing could be beneficial in reducing advanced prostate cancer and mortality in developing countries like South Africa. The Prostate Cancer Foundation of South Africa has issued guidelines on the use of PSA in prostate cancer screening, diagnosis and management, but we do not know how this test is used in our healthcare facilities. Aims and objectives: To describe modalities of PSA testing in screening and diagnosis of prostate cancer in terms of number of PSA test requests, patient demographic characteristics, type of health care facility (clinic versus hospital), prostate biopsy uptake and PSA level. Methods: This was a descriptive retrospective study of PSA tests done at the National Health Laboratory Services laboratory at Charlotte Maxeke Johannesburg Academic Hospital from January 2013 to December 2013. Results: 17 498 subjects had PSA tests. Of these 13 795 (79%) were done in Black African men (BA) while 3703 (21%)) in other racial groups (Others). More requests (62%) were from clinics versus than from hospitals (38%). The mean age for Black Africans (55.5 years SD (±13.3 years) was significantly lower than that of Others (62.9 years (±12.6 years, p<0.005), and median PSA level was significantly higher in Black African men from age 60 and above compared to Others (1.79 versus 1.53 μg/L, p<0.001). More Black Africans aged 60 and above had PSA level above age specific reference interval than others of the same age category (33% versus 26%, p<0.001). Only 17% of all men had a PSA above 4.00 μg/L which is the cut-off used by the National Health Laboratory Services. Of the four hundred and twenty-three men who underwent prostate biopsy, 213 (50%) had cancer. Fewer prostate biopsies were done in Black Africans than Others (2% vs. 4 % p=0.01), although Black African men were more likely to be diagnosed with prostate cancer on biopsy than Others (54% vs. 43%, p=0.03). Conclusion: PSA testing is a common practice in our healthcare facilities. The numbers of PSA tests done differ by age and race of patients. Black African men had lower biopsy uptake even though they were likely to be diagnosed with prostate cancer on biopsy.LG201

Prostate Specific-Antigen Testing Policy:Non-Urologists and Guideline Adherence

Het gebruik van de Prostaat-Specifiek Antigeen (PSA) test voor het screenen op prostaatkanker blijft controversieel, omdat er zowel voor- als nadelen aan de test kleven. Daarom wordt het door alle richtlijnen essentieel geacht dat artsen de patiënt adequaat informeren over deze voors en tegens, zodat de patiënt een weloverwogen beslissing kan nemen. Wij beschrijven in deze studie dat patiënten zelden volledig worden geïnformeerd door zowel huisartsen als niet-urologische medisch specialisten, waardoor patiënten niet in staat zijn om deze weloverwogen beslissing te nemen over het al dan niet ondergaan van de PSA test. De richtlijnen adviseren artsen ook altijd een rectaal toucher te verrichten bij een PSA test verzoek, om voldoende geïnformeerd te zijn over de conditie van de prostaat. Dit blijkt echter maar in 30-50% van de gevallen te worden gedaan. Ook het gehanteerde follow-up beleid na een PSA test door huisartsen en niet-urologische medisch specialisten varieert enorm en is niet in overeenstemming met de richtlijnen. In plaats van follow-up voor een matig verhoogde PSA uitslag zullen oudere patiënten en patiënten met comorbiditeit vaker gerustgesteld worden of überhaupt niet worden geïnformeerd over de uitslag, omdat deze groep patiënten mogelijk minder kans heeft op het ontwikkelen van een klinisch relevant prostaatcarcinoom. Door dit follow-up beleid worden deze patiënten verdere testen met bijkomende mogelijke schade onthouden. Dit maakt echter het verrichten van het merendeel van deze PSA testen discutabel

All care, but whose responsibility? Community juries reason about expert and patient responsibilities in prostate-specific antigen screening for prostate cancer

General practitioners have implicitly been given responsibility for guiding men’s decisions about prostate-specific antigen–based screening for prostate cancer, but patients’ expectations of the bounds of this responsibility remain unclear. We sought to explore how well-informed members of the public allocate responsibilities in prostate-specific antigen screening decision-making. In 2014, we convened two Community juries in Sydney, Australia, to address questions related to the content and timing of information provision and respective roles of patients and general practitioners in screening decisions. Participants in the first jury were of mixed gender and of all ages (n = 15); the participants in the second jury were all male and of screening age (n = 12). Both juries were presented with balanced factual evidence on the harms and benefits of prostate-specific antigen screening and expert perspectives on ethico-legal aspects of consent in medical practice. In their deliberations, jurors agreed that general practitioners should take responsibility for informing men of the options, risks and benefits of prostate-specific antigen testing, but arrived at different positions on whether or not general practitioners should also guide screening decisions. Jurors also disagreed on how much and when general practitioners should provide detailed information about biopsies and treatments. These responses suggest that for prostate-specific antigen testing, there is a public expectation that both the allocation of responsibility between general practitioners and their male patients, and the level of information provided will be tailored to individual men. In the presence of expert uncertainty, a well-informed public may have reason to embrace or resist shared decision-making processes

Prostate-Specific Antigen testing in men between 40 and 70 years in Brazil: database from a check-up program

Objectives To evaluate the PSA in a large population of Brazilian men undergone to check up, and correlate the PSA cutoffs with prostate size and urinary symptoms. Materials and Methods This is a cross sectional study performed with men between 40 and 70 years undergone to check-up. All men were undergone to urological evaluation, digital rectal examination, prostate-specific antigen, and ultrasonography The exclusion criteria were men who used testosterone in the last six months, or who were using 5 alpha-reductase inhibitors. Results A total of 5015 men with an average age of 49.0 years completed the study. Most men were white and asymptomatic. The PSA in the three different aging groups were 0.9 ± 0.7ng/dL for men between 40 and 50; 1.2 ± 0.5ng/dL for men between 50 and 60; and 1.7 ± 1.5ng/dL for men greater than 60 years (p=0.001). A total of 192 men had PSA between 2.5 and 4ng/ml. From these men 130 were undergone to prostate biopsy. The predictive positive value of biopsy was 25% (32/130). In the same way, 100 patients had PSA >4ng/mL. From these men, 80 were undergone to prostate biopsy. In this group, the predictive positive value of biopsy was 40% (32/100). The Gleason score was 6 in 19 men (60%), 7 in 10 men (31%) and 8 in 3 men (9%). Conclusions The PSA level of Brazilian men undergone to check up was low. There was a positive correlation with aging, IPSS and prostate size.Universidade Federal de São Paulo (UNIFESP) Department of UrologyHospital Israelita Albert EinsteinWake Forest UniversityUNIFESP, Department of UrologySciEL