Re: an empirical evaluation of guidelines on prostate-specific antigen velocity in prostate cancer detection

Counterpoint: Prostate-specific antigen velocity is not of value for early detection of cancer

Firm evidence shows that prostate-specific antigen (PSA) velocity is statistically associated with many prostate cancer outcomes, including those related to early detection. However, the clinical use of a marker depends on clinical and statistical significance. Before PSA velocity is used to inform decisions such as whether to perform a biopsy, evidence should be clear that doing so would improve clinical outcome. A systematic review on PSA velocity found that almost no studies had evaluated whether PSA velocity aids in clinical decision-making. Since that time, several reports have indicated that including PSA in a statistical model alongside standard predictors (eg, PSA, digital rectal examination) does not improve predictive accuracy. Specifically, performing a biopsy on men with high PSA velocity in the absence of other indications, as recommended by the NCCN Clinical Practice Guidelines in Oncology for Prostate Cancer Early Detection, would lead to many millions of unnecessary biopsies, without a corresponding number of aggressive cancers being detected. Advocates of PSA velocity have been reduced to citing a single article claiming that PSA velocity aids in clinical decision-making. The article involves selective reporting of an unusual subgroup analysis based on an extremely limited number of events. This is not to say that, in clinical practice, urologists should ignore prior PSA values: clinical judgment can be aided by careful longitudinal evaluation of PSA changes, interpreted in the context of symptoms and treatments. However, the literature clearly shows that simplistic application of PSA velocity cutoffs is not of value for early detection of prostate cancer.