Introduction

Prostate cancer remains the most commonly diagnosed non-cutaneous malignancy among American men, with an estimated 288,300 patients to be diagnosed and 34,700 deaths to occur in 2023.¹ As such, the scientific community has worked feverishly to conduct population-based screening studies and to develop new approaches for early detection. Indeed, the market is now replete with commercial laboratory biomarkers, and use of multiparametric magnetic resonance imaging (mpMRI) is now commonplace. For the practicing urologist, it is challenging to stay abreast of all these developments so as to optimize their clinically significant prostate cancer (grade group 2 or higher) minimizing the harms of early detection. To this end, the AUA commissioned a panel of experts to develop a new prostate cancer early detection guideline that began in 2021. Using the rigorous AUA process for evidence review, new guideline statements were developed to cover PSA-based screening, use of imaging/biomarkers, atypical pathology review, and biopsy techniques.

Screening For Prostate Cancer

Prostate cancer screening is a preference-sensitive decision in a clinical scenario that involves a great deal of uncertainty (eg, What is the risk of significant cancer? Will finding cancer benefit the patient?). For these reasons, the Panel continues to recommend that clinicians engage in shared decision-making (SDM) so they can make an informed choice that incorporates the patient’s preferences and values when considering screening.² The Panel further reviewed the AUA white paper² that elaborated on how the SDM process should build consensus based on clinician and patient discussion, that then leads to agreement on the decision regarding whether or not to implement screening. Indeed, given the uncertainty for many of the decisions that lead up to a prostate biopsy, the Panel encourages the use of SDM for many of the clinical decisions throughout the Early Detection Guideline.

Despite its limitations, PSA is still endorsed as the primary screening modality. The AUA review identified several studies using non-PSA–based screening, but the evidence was quite limited. However, there was robust evidence available that provided for tailoring of prostate screening. Thus, the guideline covers age- and risk-based screening, screening intervals, tailored screening based on life expectancy, and cessation of screening. If a patient decides to proceed with PSA-based screening following SDM, the patient and clinician may be confronted with the decision to undergo a prostate biopsy. Given the need to account for multiple risk factors, the AUA Panel discusses the use of various tools to aid in the estimate of risk of grade group 2 or higher prostate cancer.

Use of MRI and Biomarkers

In today’s health care market, mpMRI and urine/serum biomarkers have been developed that help supplement the risk assessment provided by clinical factors and serum PSA. Given the potential of these tests to improve accuracy or to avoid a biopsy, the literature in this area has grown significantly over the past decade. The AUA guideline summarizes commonly used tests and mpMRI, and further discusses their utility in the context of prostate cancer screening.

Biopsy Technique

In an effort to improve cancer detection while minimizing the harms of a prostate biopsy, 2 disruptive technologies have recently changed how urologists perform a prostate biopsy. The first is the development of cognitive and then software-based fusion techniques that allow clinicians to target significant MRI findings, which have led directly to wider adoption of mpMRI as a supplemental test.³ Among other key questions, the AUA guideline discusses use of systematic and targeted biopsy when the MRI is abnormal, and the number of samples to take of each MRI target. The guideline further discusses the use of both transrectal and transperineal biopsy techniques.

Conclusion

Screening and the early detection of prostate cancer remain intensely debated topics with major implications for both individual and population health. Without a doubt, we live in an exciting time with the introduction of many laboratory tests and mpMRI to the early detection armamentarium. However, with more options come more difficult decisions. Despite the exhaustive efforts undertaken by the AUA to develop this guideline, there continue to be many unanswered questions, which should prompt future research to enhance and optimize patient care.