Controversies in prostate cancer diagnosis and management

The PSA era has demonstrated an increase in the diagnosis and treatment of indolent and clinically insignificant prostate cancer. The US Preventive Services Task Force (USPSTF) issued a grade D recommendation against population-based PSA screening for men over the age of 75 in 2008 and then for all men in 2012. While the USPSTF has since backed off of their hard-line stance against PSA screening, how urologists and primary care physicians use the test has continued to be the subject of debate. Since the introduction of PSA as a key diagnostic tool, additional serum, urinary, and tissue biomarkers have emerged as potential replacements or as supplementary tools in the attempt to avoid detection of low-risk prostate that may never impact a man's longevity while identifying men who may have higher-risk disease. Advances in imaging technology, specifically prostate MRI, have also been shown to effectively risk-stratify patients, allowing counseling on the need for prostate biopsy as well as the risk of harboring clinically significant disease. The adoption of active surveillance (formerly "watchful waiting") as an option for men diagnosed with low-risk prostate cancer has reduced the overtreatment of clinically insignificant cancer, saving curative treatment through surgery or radiation for those whose who have higher-risk cancer. For select patients, focal therapy has emerged as an appealing treatment modality to avoid the sexual and urinary side effects of traditional whole gland therapy.