Smart screen.

Top Line: Rounding the bend to 2022, where do we stand with PSA screening recommendations?

The Study: The European Association of Urology is here to clear things up with 2021 screening recs that capitalize on new and robust prostate MRI data. First, a quick history lesson: the initial push for PSA screening for all led to a whole lotta treatments (and associated morbidity) for indolent disease, while the 180 circa 2012 to PSA screening for none arguably led to the notable rise in diagnosis of de novo metastatic disease and possibly even prostate cancer deaths in the ensuing decade. The stated goal from the outset of the newest guidelines, then, is to avoid overdiagnosis/overtreatment of men unlikely to experience disease-related symptoms during their lifetime while still optimizing early diagnosis of men at risk for symptomatic and/or fatal disease. In other words, let’s treat the optimal number of men necessary to continue driving the needle forward for prostate-specific mortality and quality-of-life. The result is, yes, start with an initial PSA screening at 50, then reflex risk nomogram, and then MRI if nomogram-triggered—all prior to any biopsies. Think HPV screening for women with reflex pap smear and colposcopy if triggered. Subsequent frequency of PSA screening depends on all of the above coupled with age. Figure 4 really says it all.

TBL: The most practical PSA screening guidelines yet combine PSA with clinical risk calculators and prostate MRIs before signing anyone up for a biopsy and potential oncologic treatment. | Van Poppel, Eur Urol 2021

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