Prostate-Specific Antigen Screening and Active Surveillance for High-Risk Individuals.

Abstract

Bergengren et al1 and Nelson et al2 report on 2 important and controversial topics in prostate cancer: (1) prostate-specific antigen (PSA) screening and (2) active surveillance for high-risk individuals (ie, men of African ancestry). These 2 topics highlight the complexity of current practices in both the early detection of prostate cancer and the management of localized disease. In their study, Bergengren and colleagues1 demonstrate that the use of PSA testing and the resultant increase in diagnostic activity, from 1996 to 2016, corresponded with a 15% decrease in prostate cancer deaths—at the expense of both overdiagnosis and overtreatment—when compared with a simulated scenario in which the use of diagnostic activity was held constant at the rate of testing in 1996 (the early period of routine PSA screening). The study found that the actual number of low-risk and intermediate-risk cancers was 148% higher and that the rate of definitive treatment was more than 2-fold higher compared with the simulated scenario. The modeling strategy used in this study applies both diagnostic and treatment paradigms from nearly 3 decades ago in its simulation model. This strategy, unfortunately, overemphasized past practices and does not adequately account for the significant advances that have been made in the field to date. For instance, nearly 20% of men in the observed cohort had their cancer detected after the age of 80 years; consequently, this study models screening for older men who should not be offered routine PSA testing. The last decade has seen a dramatic increase in the use of active surveillance as a management strategy for men with low-risk prostate cancers at diagnosis.3 Diagnostic tools such as multiparametric prostate magnetic resonance imaging4,5 and tissue-based molecular testing6,7 are providing clinicians with additional tools to better discriminate men at risk for prostate cancer, and they are likely to decrease the use of unnecessary prostate biopsies and the overdetection of prostate cancer. Simulation-based studies have also demonstrated that strategies such as age restriction and biennial PSA testing may reduce the burden of overdetecting favorable-risk prostate cancers.8 Shoag et al9 demonstrated that the benefit from PSA screening continues to accrue even with follow-up extending to 25 years, based on modeling statistics calibrated to population-level incidence rates in the US and the observed screening benefit from a large screening trial. Recent population studies from the US have shown an increase in the rate of incident metastatic prostate cancer since the US Preventive Services Task Force recommendation against routine screening in 2012.10 A recent study shows that the observed increase in metastatic prostate cancer in the US since 2012 likely is associated withs some decrease in PSA testing in the population.11 Bergengren and colleagues1 highlight the importance of working toward a strategy of early detection and localized treatment that aims to avoid unnecessary diagnosis and treatment for men because the benefit of screening older men and treating favorable-risk disease is marginal. However, our path to this goal should rely on strategies that do not reduce overdetection at the expense of increasing the detection of incurable and advanced cancers. Clinicians have struggled with the optimal strategy for monitoring high-risk populations of men with favorable-risk prostate cancer, such as men of African ancestry and men with strong family histories of prostate cancer. Early studies evaluating pathologic specimens from low-risk men treated with surgery suggested that active surveillance would yield unfavorable results for Black men, owing to their increased risk of disease upgrading at prostatectomy.12 However, more recent studies have + Related articles