RAMB - AGOSTO 2017

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2017; 63(8):722-725

As a counterpoint to the USPSTF recommendations, in

2013, the American Urological Association (AUA) published

its recommendations on using PSA for the early detection

of prostate cancer. The panel of urologists recommended

PSA screening every 1 to 2 years for men aged 55 to 69 years

after a decision shared between the doctor and the patient

about the risks and benefits of the test. The text further

states that, except for men with risk factors for prostate

cancer, routine use of PSA is not recommended for other

age groups or if life expectancy is less than 10-15 years.

It is reasonable to accept that universal screening of

the male population, regardless of age and family history,

may not be the best approach, but on the other hand there

are many methodological flaws in the published studies

that have not been correctly interpreted. In addition, one

important neglected point in the studies concerns the

criteria used to measure the benefit of screening, which

is usually only cancer-specific survival. The chance of

decreased metastases, quality of life or other benefits that

may result from an earlier diagnosis of the disease were

not used as a primary parameter in any of the studies.

Vickers et al. demonstrated that PSA levels around

45 years in patients with no family risk factors could pro-

vide data on the chance of developing aggressive prostate

cancer and risk of death from the tumor in the coming

decades. In 21,277 men living in Malmö in Sweden and

monitored since 1984, the authors identified that 44% of

deaths from prostate cancer occurred in patients whose

PSA value was above the 10

population percentile. When

the baseline PSA values were below the population me-

dian according to the different age ranges – namely: up

to 42 years: ≤ 0.6 ng/mL; up to 50 years: ≤ 0.7 ng/mL and

up to 55 years: ≤ 0.9 ng/mL –, the chance of death from

prostate cancer in 25 years was estimated at 0.1, 0.5 and

0.8%, respectively. These authors suggest that only three

PSA measurements, the first performed at around 45 years,

the second at the beginning of the fifth decade of life, and

the third at 60 years may be sufficient for a safe risk as-

sessment for half of the population.

More recently, the European ERSPC study, now with

almost 14 years of median follow-up, confirmed that

prostate cancer mortality in PSA screened patients de-

creased by 32%.

Thus, as additional evidence published since 2012

continues to show a progressive reduction in prostate

cancer mortality with the use of PSA, the USPSTF just

promoted a change in its guidelines in May 2017.

The new recommendation is now grade “C,” suggest-

ing that there is a benefit to the use of PSA but that the

test should be used selectively based on the professional

judgment and patient preferences, recommendations

similar to those proposed by the AUA in 2013.

Priority should be given to a shared decision between

the physician and the patient about the risks and benefits

of using PSA. The USPSTF concludes that there is a small

overall benefit after a decade with the use of PSA, but

continues to note that damages may occur during this

screening period. However, there is still a major age-re-

lated problem in this current recommendation, because

studies have predominantly included patients aged 55-70

years. Thus, the new USPSTF will not recommend PSA

for men over 70 years nor for those under 55 years, which

seems inadequate, given that it does not take into account

clinical characteristics nor individual volition.

However, this change in guidance seems to be better

than the previous one and also occurred because there

was a greater acceptance of active surveillance as a ther-

apeutic form for low risk prostate cancer. The use of this

approach was only used in 10% of low-risk prostate can-

cer cases between 2005 and 2009, and became higher

than 40% between 2010 and 2013, creating the concept

of not necessarily relating the diagnosis of prostate can-

cer with the intervention (diagnosis ≠ prostatectomy or

radiation therapy).

A recent study confirms the validity of this approach.

In the ProctecT trial, 1,643 patients with prostate cancer

GS ≤ 6 (ISUP 1) were randomized 1:1:1 among radical

prostatectomy, external radiation therapy or active sur-

veillance. After 10 years of monitoring, there was no dif-

ference in mortality from prostate cancer between the

groups, which was 1%, suggesting an equivalence of

therapeutic results and minimal risk of disease progres-

sion in this time interval. There were, however, differ-

ences between therapeutic approaches. Patients undergo-

ing active surveillance were twice as likely to develop

metastases in 10 years compared to those treated radi-

cally. Therefore, a longer monitoring period will be neces-

sary to verify if the increased risk of death among the

patients under surveillance is actually due to tumor pro-

gression or age-related comorbidities.

The Brazilian Society of Urology maintains its recom-

mendation that men over 50 years should seek a profes-

sional for an individualized evaluation. Those with first-

-degree relatives with prostate cancer should begin at age

45. Screening should be conducted after extensive discus-

sion of the risks and potential benefits. After 75 years, it

should be performed only for those with a life expec-

tancy of over 10 years.