Practical PSA Screening for PCPs and Urologists

In this episode of BackTable Urology, Dr. Aditya Bagrodia and Dr. Scott Eggener, director of the High Risk and Advanced Prostate Cancer Clinic at UChicago Medicine, discuss the importance of practical PSA screenings and shared decision making with patients. Dr. Eggener advocates for the prevention of overdiagnosis and overtreatment in prostate cancer.

First, the doctors shared their approaches to prostate screening in a high risk patient. Dr. Eggener considers patients to be at high risk for prostate cancer if they have a positive family history of prostate, breast, ovarian, or pancreatic cancer. Also, the risk of developing prostate cancer is higher in patients with African and Ashkenazi Jewish ancestries. For high risk patients, he recommends annual PSA screenings but rejects the notion of a concrete threshold number. Instead, Dr. Eggener recommends comparing PSA screening values to the patient’s original baseline PSA value. He emphasizes that because the majority of prostate cancers are slow growing, a rapidly rising PSA can mostly be attributed to infection, inflammation, or another inciting event. For this reason, he always performs a repeat PSA screening a couple months after the initial abnormal test is obtained.

In healthy patients with no family history of cancer, Dr. Eggener recommends initial PSA screening between 45-55 years old. Additionally, a “normal” PSA value is age-dependent. He estimates that a value of 0.6 ng/ml is normal for patients in their 40s, while 0.9 ng/ml is normal for patients in their 50s. For any value above 1.5 ng/ml, he will perform a digital rectal exam (DRE) to gain more information about prostate size.

In patients with an elevated PSA as well as an abnormal DRE, Dr. Eggener will obtain MRI imaging to look for prostatic lesions. If the MRI is clear and the patient has no other risk factors besides an elevated PSA, he will recommend PSA screening every 1-2 years. If the MRI shows prostatic lesions, he will continue with a biopsy. However, Dr. Eggener acknowledges that cancer may be a possibility in patients with clear MRI scans, as imaging can sometimes be inaccurate. Thus, he sometimes chooses to biopsy high-risk patients with normal MRI scans as well.

Finally, the doctors discuss the advantages and disadvantages of new screening tools, such as Next-Generation biomarkers and polygenic risk scores, in diagnosing prostate cancer.