Prostate cancer is the still the second most common type of cancer in men worldwide, even though there has been a decrease in the PSA screening since 2018.[1,2] As of 2020, prostate cancer is the most prevalent cancer in men in 112 nations by incidence. It makes up 15% of all male malignancies and one out of every 14 cancers diagnosed worldwide. As per the recent report of the lancet commission, the annual number of new cases is expected to increase from 1.4 million in 2020 to 2.9 million by 2040.[3]
The significantly lower incidence and mortality rates of prostate cancer in Asian nations may be due to a number of factors such as genetic predisposition and culturally influenced lifestyles.[1]
The American Urological Association/Society of Urological Oncology in 2023 released two-part guideline recommendations for early detection of prostate cancer, which was published in the journal of urology. This guideline provides a step-by-step approach to facilitate screening and biopsy and follow up patients with prostate cancer. The part 1 guideline for early detection of prostate cancer specifically deals with screening, and part 2 covers discussion based on the initial and repeat biopsy. The current guidelines emphasize the importance of early detection of cancer based on the levels of PSA, initial and repeated biopsy, and the technique of biopsy.[4]
The current recommendations give more importance to shared decision-making (SDM), with screening based on the age group and risk category to identify clinically significant prostate cancer as GG2 or higher as GG2+. In terms of patient counseling for decisions that are responsive to preferences, SDM is regarded as revolutionary,[4] in contrast to 2013 guidelines which emphasized SDM for screening of men in the age group of 55 to 69 years.[5,6]
PSA level assessment has been the cornerstone in the early detection of prostate cancer, even though the levels of PSA may vary in accordance with the age. AUA/SUO recommends PSA level assessment as the first line of screening, with repeat evaluation of the PSA levels prior to any secondary evaluation with another biomarker, radiological assessment, or confirmation with biopsy.
The panel of experts have also changed the age range at which screening should be initiated. Screening may be initiated in patients with age between 45 and 50 years who have average risk, while in patients with high risk of prostate cancer, such as strong family history, genetic mutation, and black ancestry, the age of screening initiation has been decreased to 40–45 years.[4] This change was a major highlight in comparison to AUA 2013, in which the panel discouraged routine screening of men less than 40 years of age, in men between 40 and 54 years, for those not at high risk, and in patients with life expectancy less than 10 to 15 years or in patients above 70 years of age.[5]
Based on two randomized trials, ERSPC7 and the Goteborg population-based prostate cancer screening trial, the authors recommended a screening interval every 2 to 4 years in the age group of 50 to 69 years. It was also decided that, following SDM, practitioners can tailor the rescreening interval or choose to cease screening based on patient preference, age, PSA, prostate cancer risk, life expectancy, and general health.[4]
Digital rectal examination was not suggested as a screening method in view of the low positive predictive value of prostate cancer based on the PROBASE trial. The panel advised the practitioners to use DRE as an adjunct along with serum levels of PSA in the early detection of prostate cancer. PSA velocity was not recommended as a sole indicator for a secondary biomarker, radiological imaging, or biopsy.[4]
While there are many risk factors contributing prostate cancer, the authors suggest using validated risk calculators during the process of SDM regarding prostate biopsy. Both the patient and the practitioner may believe that a patient has a low probability of developing clinically significant prostate cancer when determining their risk for the disease based on the norms of history, laboratory parameters, or data based on radiological findings. AUA/SUO 2023 panel’s decision is to avoid a prostate biopsy in such cases after SDM, even when there may be some clinical characteristics that suggest a risk for prostate cancer such as a slightly higher PSA level.[4]
To conclude, the AUA/SUO 2023 updated guidelines provide more insight in the early detection of clinically significant prostate cancer, which helps in facilitating optimal patient care and improve the management with an aim focused in the reduction of mortality associated with metastatic prostate cancer.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
REFERENCES
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