Early Detection of Prostate Cancer
Publication Date: April 25, 2023
Last Updated: April 26, 2023
PSA Screening
Clinicians should engage in shared decision-making (SDM) with people for whom prostate cancer screening would be appropriate and proceed based on a person’s values and preferences. (Clinical Principle, )
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When screening for prostate cancer, clinicians should use PSA as the first screening test. (Strong, A)
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For people with a newly elevated PSA, clinicians should repeat the PSA prior to a secondary biomarker, imaging, or biopsy. (Expert Opinion, )
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Clinicians may begin prostate cancer screening and offer a baseline PSA test to people between ages 45 to 50 years. (Conditional, B)
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Clinicians should offer prostate cancer screening beginning at age 40 to 45 years for people at increased risk of developing prostate cancer based on the following factors: Black ancestry, germline mutations, strong family history of prostate cancer. (Strong, B)
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Clinicians should offer regular prostate cancer screening every 2 to 4 years to people aged 50 to 69 years. (Strong, A)
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Clinicians may personalize the re-screening interval, or decide to discontinue screening, based on patient preference, age, PSA, prostate cancer risk, life expectancy, and general health following SDM. (Conditional, B)
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Clinicians may use digital rectal exam (DRE) alongside PSA to establish risk of clinically significant prostate cancer. (Conditional, C)
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For people undergoing prostate cancer screening, clinicians should not use PSA velocity as the sole indication for a secondary biomarker, imaging, or biopsy. (Strong, B)
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Clinicians and patients may use validated risk calculators to inform the SDM process regarding prostate biopsy. (Conditional, B)
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When the risk of clinically significant prostate cancer is sufficiently low based on available clinical, laboratory, and imaging data, clinicians and patients may forgo near-term prostate biopsy. (Clinical Principle, )
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Initial Biopsy
Clinicians should inform patients undergoing a prostate biopsy that there is a risk of identifying a cancer with a sufficiently low risk of mortality that could safely be monitored with active surveillance (AS) rather than treated. (Clinical Principle, )
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Clinicians may use magnetic resonance imaging (MRI) prior to initial biopsy to increase the detection of Grade Group (GG) 2+ prostate cancer. (Conditional, B)
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Radiologists should utilize PI-RADS in the reporting of multi-parametric MRI (mpMRI) imaging. (Moderate, C)
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For biopsy-naïve patients who have a suspicious lesion on MRI:
clinicians should perform targeted biopsies of the suspicious lesion (Moderate, C)
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and may also perform a systematic template biopsy (Conditional, C)
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For patients with both an absence of suspicious findings on MRI and an elevated risk for GG2+ prostate cancer, clinicians should proceed with a systematic biopsy. (Moderate, C)
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Clinicians may use adjunctive urine or serum markers when further risk stratification would influence the decision regarding whether to proceed with biopsy. (Conditional, C)
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For patients with a PSA > 50 ng/mL and no clinical concerns for infection or other cause for increased PSA (e.g., recent prostate instrumentation), clinicians may omit a prostate biopsy in cases where biopsy poses significant risk or where the need for prostate cancer treatment is urgent (e.g., impending spinal cord compression). (Expert Opinion, )
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Repeat Biopsy
Clinicians should communicate with patients following biopsy to review biopsy results, reassess risk of undetected or future development of GG2+ disease, and mutually decide whether to discontinue screening, continue screening, or perform adjunctive testing for early reassessment of risk. (Clinical Principle, )
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Clinicians should not discontinue prostate cancer screening based solely on a negative prostate biopsy. (Strong, C)
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After a negative biopsy, clinicians should not solely use a PSA threshold to decide whether to repeat the biopsy. (Strong, B)
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If the clinician and patient decide to continue screening after a negative biopsy, clinicians should re-evaluate the patient within the normal screening interval (two to four years) or sooner, depending on risk of clinically significant prostate cancer and life expectancy. (Clinical Principle, )
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At the time of re-evaluation after negative biopsy, clinicians should use a risk assessment tool that incorporates the protective effect of prior negative biopsy. (Strong, B)
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After a negative initial biopsy in patients with low probability for harboring GG2+ prostate cancer, clinicians should not reflexively perform biomarker testing. (Clinical Principle, )
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After a negative biopsy, clinicians may use blood, urine, or tissue-based biomarkers selectively for further risk stratification if results are likely to influence the decision regarding repeat biopsy or otherwise substantively change the patient’s management. (Conditional, C)
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In patients with focal (one core) high-grade prostatic intraepithelial neoplasia (HGPIN) on biopsy, clinicians should not perform immediate repeat biopsy. (Moderate, C)
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In patients with multifocal HGPIN, clinicians may proceed with additional risk evaluation, guided by PSA/DRE and mpMRI findings. (Expert Opinion, )
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In patients with atypical small acinar proliferation (ASAP), clinicians should perform additional testing. (Expert Opinion, )
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In patients with atypical intraductal proliferation (AIP), clinicians should perform additional testing. (Expert Opinion, )
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In patients undergoing repeat biopsy with no prior prostate MRI, clinicians should obtain a prostate MRI prior to biopsy. (Strong, C)
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In patients with indications for a repeat biopsy who do not have a suspicious lesion on MRI, clinicians may proceed with a systematic biopsy. (Conditional, B)
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In patients undergoing repeat biopsy and who have a suspicious lesion on MRI:
clinicians should perform targeted biopsies of the suspicious lesion (Moderate, C)
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and may also perform a systematic template biopsy. (Conditional, C)
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Biopsy Technique
Clinicians may use software registration of MRI and ultrasound images during fusion biopsy, when available. (Expert Opinion, )
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Clinicians should obtain at least two needle biopsy cores per target in patients with suspicious prostate lesion(s) on MRI. (Moderate, C)
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Clinicians may use either a transrectal or transperineal biopsy route when performing a biopsy. (Conditional, C)
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Recommendation Grading
Disclaimer
The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.
Overview
Title
Early Detection of Prostate Cancer
Authoring Organizations
American Urological Association
Society of Urologic Oncology
Publication Month/Year
April 25, 2023
Last Updated Month/Year
December 20, 2023
Supplemental Implementation Tools
Document Type
Guideline
Country of Publication
US
Document Objectives
The summary presented herein covers recommendations on the early detection of prostate cancer and provides a framework to facilitate clinical decision-making in the implementation of prostate cancer screening, biopsy, and follow-up.
Inclusion Criteria
Male, Adult, Older adult
Health Care Settings
Ambulatory, Outpatient, Radiology services
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Diagnosis, Assessment and screening
Diseases/Conditions (MeSH)
D011467 - Prostate, D017430 - Prostate-Specific Antigen, D055088 - Early Detection of Cancer
Keywords
prostate cancer, PsA, Early Detection, cancer screening, early detection of cancer, prostate imaging
Source Citation
Wei JT, Barocas D, Carlsson S, Coakley F, Eggener S, Etzioni R, Fine SW, Han M, Kim SK, Kirkby E, Konety BR, Miner M, Moses K, Nissenberg MG, Pinto PA, Salami SS, Souter L, Thompson IM, Lin DW. Early Detection of Prostate Cancer: AUA/SUO Guideline Part I: Prostate Cancer Screening. J Urol. 2023 Apr 25:101097JU0000000000003491. doi: 10.1097/JU.0000000000003491. Epub ahead of print. PMID: 37096582.
Wei JT, Barocas D, Carlsson S, Coakley F, Eggener S, Etzioni R, Fine SW, Han M, Kim SK, Kirkby E, Konety BR, Miner M, Moses K, Nissenberg MG, Pinto PA, Salami SS, Souter L, Thompson IM, Lin DW. Early Detection of Prostate Cancer: AUA/SUO Guideline Part II: Considerations for a Prostate Biopsy. J Urol. 2023 Apr 25:101097JU0000000000003492. doi: 10.1097/JU.0000000000003492. Epub ahead of print. PMID: 37096575.
Methodology
Number of Source Documents
284
Literature Search Start Date
May 1, 2000
Literature Search End Date
November 21, 2022