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NCCN stresses importance, efficacy of PSA testing in high-risk men
The National Comprehensive Cancer Network has updated its guidelines to address ERSPC and PLCO trial results.
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In the wake of recent confusion about the implications of data from two PSA screening trials, the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial and the European Randomized Study of Screening for Prostate Cancer, the National Comprehensive Cancer Network has updated its Guidelines for Prostate Cancer Early Detection. In the guidelines NCCN stressed that PSA screening does improve the mortality rate in high-risk populations when performed intelligently and combined with prompt, effective, high-quality treatment.
“PSA testing has saved thousands of lives and continues to be an important tool in the fight against prostate cancer,” Mark Kawachi, MD, associate professor of surgery, urology and urologic oncology at City of Hope Comprehensive Cancer Center in Duarte, Calif., said in a press release.
Kawachi, who is also chair of the NCCN Guideline for the Prostate Cancer Early Detection Panel, and other panel members incorporated the results of the ERSPC trial into the “Suggested Talking Points for Discussion with a Potential Screenee about the Pros and Cons of PSA Testing” guidelines.
This information summarizes the ERSPC trial findings and reiterates that PSA screening decreased the mortality rate in men who were screened, despite also resulting in an increased the rate of overdiagnosis.
Unclear findings discussed
Findings from the ERSPC showed a reduction in the number of prostate cancer-related deaths in a PSA-screened group (n=214) vs. the group not screened (n=326). PSA-based screening for prostate cancer also resulted in a 20% reduction in the mortality rate (95% CI, 0.65-0.98).
The findings also showed, however, that 1,410 men would need to be offered screening and an additional 48 would need to be treated to prevent one prostate cancer-related death during a 10-year period, according to data previously published in HemOnc Today.
A flaw of the ERSPC was the lack of information about family history or specification of the racial composition of patients, according to Kawachi.
“Past research indicates that [black] men as well as men with a family history of prostate cancer have a significantly increased risk for developing the disease,” he said.
PLCO
Conflicting results about prostate cancer screening were observed in the PLCO screening trial as well. At 10 years, 3,452 men in the screening group were diagnosed with cancer vs. only 2,974 in the control group (rate ratio=1.17; 95% CI, 1.11-1.22); however, the increased number of cancer diagnoses did not result in a lower mortality rate.
At seven years follow-up, there were 50 prostate cancer deaths in the screening group and 44 in the control group (rate ratio=1.13; 95% CI, 0.75-1.70). At 10 years, there were 92 prostate cancer-related deaths group who were screened and 82 in the control group (rate ratio=1.11; 95% CI, 0.83-1.50).
Findings from the PLCO trial demonstrated that PSA screening did not reduce the risk for death from prostate cancer; it also lacked in heterogeneity and included very few blacks or patients with a family history of prostate cancer, according to an NCCN press release.
Kawachi noted confusion with terminology as another possible cause for unclear standards for PSA testing: “Some of the controversy with the recent trials assessing the benefits of PSA testing stems from people confusing early detection with screening. It is imperative to distinguish the two terms from each other and understand that screening implies testing a random group of participants whereas early detection targets a select group of patients whose need is greatest,” he said.
Recommendations
The updated NCCN Guidelines emphasize that it is important to note that the Guidelines for Prostate Cancer Early Detection are for the purpose of detecting cancer early in high-risk men, not the screening of mass populations. They are specifically for men opting to participate in an early detection program after receiving appropriate counsel, according to the panel.
An important update made to the NCCN Guidelines is a higher PSA of 1.0 ng/mL that would prompt men at high risk to have more frequent screenings. Thus, the guidelines recommend that at age 40, men at high risk be offered a baseline PSA and digital rectal exam, and if they have a PSA ≥1.0 ng/mL, they should have annual follow-ups. If they have a PSA <1.0 ng/mL, the recommendation is that they be screened again at age 45 years.
The NCCN Guideline Panel members acknowledge that there is no “right” answer about PSA testing for everyone, rather that each man should make an informed decision with his physician.
The NCCN position regarding the use of PSA in the detection of prostate cancer is a logical and well considered approach to individuals at risk of prostate cancer ... especially those at high risk (positive family history and/or blacks). The NCCN discussion highlights the critical need for continued exploration of the optimal use of PSA in the detection of prostate cancer and the delineation of the clinical risk of cancers detected through PSA 'screening.'
– Donald L. Trump, MD
HemOnc Today Editorial Board member