MSKCC prostate cancer screening guidelines – is it the way forward?
Reviewed by Gokul Vignesh Kanda Swamy

The Memorial Sloan Kettering Cancer Center (MSKCC) developed prostate cancer screening recommendations first in 2011 as a response to three limitations of previous screening guidelines: insufficient evidence base, failure to link screening with treatment, and lack of risk stratification. To aid in maximising the benefits and minimising the harm of screening, the recommendations focused on certain key clinical questions. For men who opt for screening starting at age 45, do prostate specific antigen (PSA) without digital rectal examination (DRE). If PSA ≥3ng/mL: consider prostate biopsy; if PSA ≥1 but <3ng/mL: return for PSA testing every two to four years; if PSA <1ng/mL: return for PSA testing at 6-10 years. PSA testing should end at age 60 for men with PSA ≤1ng/mL; between 60-70, consider biopsy if PSA ≥3ng/mL, if PSA ≥2 but <3ng/mL, return for PSA testing every two to four years and PSA >1 but <2ng/mL continued screening every two to four years or no further screening according to patient preference. After 70, no screening, unless a man is very healthy and has a higher than average PSA and no screening for all men after 75. The decision to biopsy a man with a PSA >3ng/mL should be based on a variety of factors including repeat PSA for confirmatory testing, DRE results, and work-up for benign disease. Also, age, co-morbidities, race, patient preference, 5α-reductase inhibitor (5-ARI) use, prior biopsy should be considered. Additional investigations such as a free-to-total PSA ratio, the Prostate Health Index or 4Kscore, or urinary testing of PCA3, can also be informative in some patients. The key aspect is PSA level by itself is not an indicator for biopsy. They are to be applied for men in good health and not based on 10-year life expectancy which is not an evidence-based approach. The main advantage of this system is that it allows risk stratification of patients when it comes to follow-up rather than following generic guidelines. These recommendations are based on three studies – the European Randomized study of Screening for Prostate Cancer (ERSPC), the control arm of the Prostate Cancer Prevention Trial (PCPT) and the Malmö Preventative Project study (Malmö cohort). 

The Memorial Sloan Kettering Cancer Center Recommendations for Prostate Cancer Screening.
Vickers AJ, Eastham JA, Scardino PT, Lilja H.
UROLOGY
2006;91:12-18.