Taking Early Detection Further: Prostate Cancer
Digital rectal examination of the prostate is considered unsuitable for early detection, and there is currently no effective early detection program. Urologist Prof. Peter Albers calls for an organized, risk-adapted screening program based on a PSA test starting at age 50 and proposes low-barrier approaches that could revolutionize early cancer detection.
Prof. Albers, how do you assess the current options for prostate cancer screening in Germany?
Unfortunately, there is practically nothing available for men at the moment: The digital rectal exam is an ineffective screening method that leads men to have their PSA levels tested out-of-pocket—at the wrong age, too frequently, and without risk stratification. The worst part is this: if you leave it up to each individual, you are effectively triggering overdiagnosis and overtreatment.
The Joint Federal Committee (G-BA) is currently reviewing a risk-adapted screening strategy based on a man’s individual risk, which is determined using a baseline PSA level measured around age 50. They have long favored this approach.
This algorithm has been tested for ten years now, even in several European countries. Using a baseline PSA level determined around age 50, we can immediately filter out about 80 percent of men who are not at increased risk. This information remains valid for the next five to even ten years. If the baseline PSA is above 3 ng/ml, an MRI is performed to improve diagnostic accuracy and prevent unnecessary biopsies.
The PSA level is strongly correlated with age: At age 50, only about three percent of men exceed the critical threshold of 3 ng/ml. By age 55, that figure rises to seven percent. This is the key to cost-effectively identifying men with a low risk of prostate cancer using an early baseline PSA level. As men age, they increasingly have PSA levels above three; however, these levels usually have nothing to do with prostate cancer but lead to follow-up diagnostic tests and, frequently, unnecessary treatments.
Among 100 50-year-old men with a PSA level above three, approximately 30 have prostate cancer. If an MRI is then performed and only men with abnormal findings undergo a biopsy, the number of men who actually have a tumor rises to 70 out of 100. This improves the detection rate and significantly reduces invasive diagnostic procedures without overlooking tumors that require treatment.
And what about overdiagnosis?
The tumors detected through the combination of a high PSA level and pathological MRI findings are highly likely to be significant—meaning they would be life-threatening without treatment. In the past, 80 percent of the tumors we detected were ones we didn’t even want to see. That’s slowly changing; we’re now at nearly 80 percent significant tumors and 20 percent overdiagnosis. This brings us in line with mammography screening, where approximately 20 percent of the detected tumors do not require immediate treatment either.
But doesn’t that mean a lot of men have to undergo MRI scans?
Yes, in fact, the algorithm currently results in 60 to 70 percent of MRI scans with no findings—which is an expensive undertaking.
Can’t MRI become cheaper?
In our future studies, we favor so-called “biparametric” measurements without contrast agents. Incidentally, this is also better because we’re dealing with healthy men. This reduces the cost to about 200 euros per examination—but that’s probably still too much for a comprehensive screening strategy.
What we need is an additional screening step between the PSA test and the MRI to reduce this high number of MRIs. There are already ideas in this regard that we’re currently evaluating: We’re investigating whether prostate volume plays a role—a factor that can be easily determined with ultrasound. Studies have shown that in younger men with a large prostate, a higher PSA level isn’t actually that relevant. This means we now want to perform an MRI only on men with a small prostate and a high PSA level. This has already been tested in Finland.
80 percent of men would have ten years of peace of mind
Prof. Dr. Peter Albers is Director of the Department of Urology at the University Hospital of Düsseldorf
The success of early detection programs stands or falls with the participation rate. In previous studies, this rate was particularly low, at only about 20 percent. Are there any ideas for improvement?
We’re working on it. Together with partners, we’re developing modern ways to disseminate information so that we reach the right people—not just men who are already health-conscious. We’re also testing the possibility of using capillary blood from a fingertip for PSA testing. This could then be done, for example, in a very accessible way at pharmacies; it doesn’t require medically trained staff.
To create more equitable access to preventive care, we’re also developing entirely different ideas: Together with social scientists from Mannheim, we’ve submitted a proposal to a foundation to fund a “Prostate Mobile,” which would specifically serve underprivileged neighborhoods.
If you could implement a single change today—regardless of cost or political hurdles—what would it be and why?
Quite clearly: Determining the baseline PSA level for all men aged 50—and doing so in an organized manner, by invitation. Then we could reassure about 80 percent of those tested and see them again for a follow-up in 5 to 10 years, rather than annually as is currently the case. This strategy would save a lot of money that would then be needed for the other 20 percent who have elevated PSA levels. That’s the take-home message!
And what would be even better?
My vision: Everyone receives an invitation to a comprehensive preventive health checkup in middle age. During a single appointment, patients would be screened for multiple types of cancer or have risk scores calculated. Cardiovascular markers such as LDL or lipoprotein A would also be measured. A one-stop-shop solution would be ideal. But to implement something like this, we’d probably need a Ministry of Prevention.
Prof. Dr. Peter Albers is Director of the Department of Urology at the University Hospital of Düsseldorf and Head of the Department of Personalized Early Detection of Prostate Cancer at the German Cancer Research Center.
PROBASE Collaboration Partners and Project Leaders:
Prof. Ulrike Haug, Head of the Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology
Prof. Heinz-Peter Schlemmer, Head of the Department of Radiology, DKFZ
Dr. Petra Seibold, Department of Personalized Early Detection of Prostate Cancer, DKFZ
Dr. Susanne Weg-Remers, Head of the Cancer Information Service, DKFZ
Prof. Hajo Zeeb, Head of the Department of Prevention and Evaluation, Leibniz Institute for Prevention Research and Epidemiology
Interview: Dr. Sibylle Kohlstädt, Press Spokesperson for the DKFZ