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Overview
Prostate cancer screening is an attempt to find unsuspected cancers. Screening tests may lead to more specific follow-up tests such as a biopsy, where small cores of the prostate are removed for closer study. Prostate cancer screening options include the digital rectal exam and the prostate specific antigen (PSA) blood test. Screening for prostate cancer is controversial because it is not clear if the benefits of screening outweigh the risks of follow-up diagnostic tests and cancer treatments.
Prostate cancer is usually a slow-growing cancer, very common among older men. In fact, most prostate cancers never grow to the point where they cause symptoms, and most men with prostate cancer die of other causes before prostate cancer has an impact on their lives. The PSA screening test may detect these small cancers that would never become life threatening. Doing the PSA test in these men may lead to overdiagnosis, including additional testing and treatment. Follow-up tests, such as prostate biopsy, may cause pain, bleeding and infection. Prostate cancer treatments may cause urinary incontinence and erectile dysfunction. Therefore, it is essential that the risks and benefits of diagnostic procedures and treatment be carefully considered before PSA screening.
Several medical societies have not found sufficient evidence to support routine screening for prostate cancer - but the American Urological Association supports annual screening and digital examination for men over 50 years old - and starting earlier for 'men at high risk (those with a family history of prostate cancer or African American men)'. [1]
- In 2002, the U.S. Preventive Services Task Force (USPSTF) concluded that the evidence was insufficient to recommend for or against routine screening for prostate cancer using PSA testing or digital rectal examination (DRE).[2] The previous 1995 USPSTF recommendation was against routine screening.
- In 1997, American Cancer Society (ACS) guidelines began recommending that beginning at age 50 (age 45 for African-American men and men with a family history of prostate cancer, and since 2001, age 40 for men with a very strong family history of prostate cancer), PSA testing and DRE be offered annually to men who have a life-expectancy of 10 or more years (average life expectancy is 10 years or more for U.S. men under age 76)[3] along with information on the risks and benefits of screening.[4] The previous ACS recommendations since 1980 had been for routine screening for prostate cancer with DRE annually beginning at age 40, and since 1992 had been for routine screening with DRE and PSA testing annually beginning at age 50.[5]
- The 2007 National Comprehensive Cancer Network (NCCN) guideline recommends offering a baseline PSA test and DRE at ages 40 and 45 and annual PSA testing and DRE beginning at age 50 (with annual PSA testing and DRE beginning at age 40 for African-American men, men with a family history of prostate cancer, and men with a PSA ≥ 0.6 ng/mL at age 40 or PSA > 0.6 ng/mL at age 45) through age 80, along with information on the risks and benefits of screening. Biopsy is recommended if DRE is positive or PSA ≥ 4 ng/mL, and biopsy considered if PSA > 2.5 ng/mL or PSA velocity ≥ 0.35 ng/mL/year when PSA ≤ 2.5 ng/mL.[6]
- Some U.S. radiation oncologists and medical oncologists who specialize in treating prostate cancer recommend obtaining a baseline PSA in all men at age 35[7] or beginning annual PSA testing in high risk men at age 35.[8]
- The American Urological Association Patient Guide to Prostate Cancer.[9]
Since there is no general agreement that the benefits of PSA screening outweigh the harms, the consensus is that clinicians use a process of shared decision-making that includes discussing with patients the risks of prostate cancer, the potential benefits and harms of screening, and involving the patients in the decision.[10]
However, because PSA screening is widespread in the United States, following the recommendations of major scientific and medical organizations to use shared decision-making is legally perilous in some U.S. states.[11] In 2003, a Virginia jury found a family practice residency program guilty of malpractice and liable for $1 million for following national guidelines and using shared decision-making, thereby allowing a patient (subsequently found to have a high PSA and incurable advanced prostate cancer) to decline a screening PSA test, instead of routinely ordering without discussion PSA tests in all men ≥ 50 years of age as four local physicians testified was their practice, and was accepted by the jury as the local standard of care.[12]
An estimated 20 million PSA tests are done per year in North America and possibly 20 million more outside of North America.[13]
- In 2000, 34.1% of all U.S. men age ≥ 50 had a screening PSA test within the past year and 56.8% reported ever having a PSA test.[10]
- In 2000, 33.6% of all U.S. men age 50–64 and 51.3% of men age ≥ 65 had a PSA test within the past year.[14]
- In 2005, 33.5% of all U.S. men age 50–64 had a PSA test in the past year.
- 37.5% of men with private health insurance, 20.8% of men with Medicaid insurance, 14.0% of currently uninsured men, and 11.5% of men uninsured for > 12 months.[15]
- In 2000–2001, 34.1% of all Canadian men age ≥ 50 had a screening PSA test within the past year and 47.5% reported ever having a screening PSA test.[16]
- Canadian men in Ontario were most likely to have had a PSA test within the past year and men in Alberta were least likely to have had a PSA test with the past year or ever.[17]
Interpreting the results of screening tests
Two clinical prediction rules help predict the probability of cancer based on the the level of the prostate-specific antigen and other clinical findings.[18][19]
Evidence for efficacy
Randomized controlled trials
One randomized controlled trial found significant reduction in death from screening.[20] However, the intention to treat analysis showed no benefit.
A secondary analysis of a randomized controlled trial suggests screening for prostate cancer every 4 years is adequate. The screening comprises a PSA blood test, a digital rectal exam, and a transrectal ultrasound. "Very few, if any, aggressive prostate cancers escape (this) screening."[21]
Decision analyses
In the absence of well done randomized controlled trials, a decision analysis can estimate the benefit of screening. [22][23] One analysis found that approximately 303 men would number need to be screened with a "strategy of PSA testing at ages 40 and 45 years followed by biennial testing beginning at age 50" to prevent one death from prostate cancer.[23]
Clinical practice guidelines
Clinical practice guidelines for prostate cancer screening are controversial because the benefits of screening may not outweigh the risks of follow-up diagnostic tests and cancer treatments:
- "the evidence is insufficient to recommend for or against routine screening for prostate cancer using prostate-specific antigen (PSA) testing or digital rectal examination (DRE). This is a grade I recommendation"
- American Cancer Society, in 2001, recommended:[27][28][29]
- "The PSA test and the DRE should be offered annually beginning at age 50 to men who have a life expectancy of at least 10 years. Men at high risk should begin testing at age 45. Information should be provided to patients about benefits and limitations of testing."
The ACS recommends that individual men discuss the potential benefits and risks of testing with their doctors in order to make an informed decision on whether or not to be tested. Screening should be offered annually to African-American men and those with a family history of prostate cancer upon reaching 45 years. Other racial and ethnic groups, such as Asian- and Hispanic-Americans have a lower risk of prostate cancer, and may not benefit from screening. Screening is likely not useful for men over age 70 or with other significant medical problems and a life expectancy of fewer than 10 years.
References
- ↑ Early Detection of Prostate Cancer, American Urological Association, Washington, D.C., revised: October 2008.Accessed: 12-01-2008
- ↑ US Preventive Services Task Force (2002). "Screening for Prostate Cancer". Agency for Healthcare Research and Quality. Unknown parameter
|month=ignored (help) USPSTF (2002). "Screening for prostate cancer: recommendation and rationale" (PDF). Ann Intern Med. 137 (11): 915–6. PMID 12458992. Unknown parameter|month=ignored (help)
Harris R, Lohr KN (2002). "Screening for prostate cancer: an update of the evidence for the U.S. Preventive Services Task Force" (PDF). Ann Intern Med. 137 (11): 917–29. PMID 12458993. Unknown parameter|month=ignored (help) - ↑ Arias E (2006). "United States Life Tables, 2003" (PDF). Natl Vital Stat Rep. 54 (14): 1–40. PMID 16681183. Unknown parameter
|month=ignored (help) - ↑ von Eschenbach A, Ho R, Murphy GP, Cunningham M, Lins N (1997). "American Cancer Society guideline for the early detection of prostate cancer: update 1997" (PDF). CA Cancer J Clin. 47 (5): 261–4. doi:10.3322/canjclin.47.5.261. PMID 9314820. Unknown parameter
|month=ignored (help) ACS (2007). "Prostate Cancer: Early Detection". Retrieved 2007-11-19. Unknown parameter|month=ignored (help)
Smith RA, Cokkinides V, Eyre HJ (2007). "Cancer screening in the United States, 2007: a review of current guidelines, practices, and prospects" (PDF). CA Cancer J Clin. 57 (2): 90–104. PMID 17392386. Unknown parameter|month=ignored (help)
Smith RA, Cokkinides V, Eyre HJ (2006). "American Cancer Society guidelines for the early detection of cancer, 2006" (PDF). CA Cancer J Clin. 56 (1): 11–25. PMID 16449183. Unknown parameter|month=ignored (help) - ↑ ACS (2007). "Chronological History of ACS Recommendations on Early Detection of Cancer". Unknown parameter
|month=ignored (help) - ↑ NCCN (2007). "Prostate Cancer Early Detection V.2.2007" (PDF). NCCN Clinical Practice Guidelines in Oncology. Unknown parameter
|month=ignored (help) - ↑ "Study suggests value of regular PSA tests for tracking prostate cancer". Dana-Farber Cancer Institute. 2004. Unknown parameter
|month=ignored (help) Kladko B (2005). "Prostate cancer test gets another look". The Boston Globe. Unknown parameter|month=ignored (help) - ↑ Strum SB, Pogliano D (2005). "What every doctor who treats male patients should know" (PDF). PCRI Insights. 8 (2): 4–5. Unknown parameter
|month=ignored (help) - ↑ American Urological Association (AUA) (2008). "Prostate Cancer Patient Guide" (PDF). AUA Patient Guidelines.
- ↑ 10.0 10.1 Ross LE, Coates RJ, Breen N, Uhler RJ, Potosky AL, Blackman D (2004). "Prostate-specific antigen test use reported in the 2000 National Health Interview Survey". Prev Med. 38 (6): 732–44. doi:10.1016/j.ypmed.2004.01.005. PMID 15193893.
- ↑ Lewis MH, Gohagan JK, Merenstein DJ (2007). "The locality rule and the physician's dilemma: local medical practices vs the national standard of care". JAMA. 297 (23): 2633–7. doi:10.1001/jama.297.23.2633. PMID 17579232.
- ↑ Merenstein D (2004). "Winners and losers". JAMA. 291 (1): 15–6. doi:10.1001/jama.291.1.15. PMID 14709561.
- ↑ De Angelis G, Rittenhouse HG, Mikolajczyk SD, Blair Shamel L, Semjonow A (2007). "Twenty years of PSA: from prostate antigen to tumor marker". Rev Urol. 9 (3): 113–23. PMID 17934568.
- ↑ Swan J, Breen N, Coates RJ, Rimer BK, Lee NC (2003). "Progress in cancer screening practices in the United States: results from the 2000 National Health Interview Survey". Cancer. 97 (6): 1528–40. doi:10.1002/cncr.11208. PMID 12627518.
- ↑ Ward E, Halpern M, Schrag N, Cokkinides V, DeSantis C, Bandi P, Siegel R, Stewart A, Jemal A (2008). "Association of insurance with cancer care utilization and outcomes" (PDF). CA Cancer J Clin. 58 (1): 9–31. doi:10.3322/CA.2007.0011. PMID 18096863. Unknown parameter
|month=ignored (help) - ↑ Beaulac JA, Fry RN, Onysko J (2006). "Lifetime and recent prostate specific antigen (PSA) screening of men for prostate cancer in Canada". Can J Public Health. 97 (3): 171–6. PMID 16827400.
- ↑ Gibbons L, Waters C (2003). "Prostate cancer--testing, incidence, surgery and mortality" (PDF). Health Rep. 14 (3): 9–20. PMID 12816012. Unknown parameter
|month=ignored (help) - ↑ Nam RK, Toi A, Klotz LH; et al. (2007). "Assessing individual risk for prostate cancer". J. Clin. Oncol. 25 (24): 3582–8. doi:10.1200/JCO.2007.10.6450. PMID 17704405.
- ↑ Thompson IM, Ankerst DP, Chi C; et al. (2006). "Assessing prostate cancer risk: results from the Prostate Cancer Prevention Trial". J. Natl. Cancer Inst. 98 (8): 529–34. doi:10.1093/jnci/djj131. PMID 16622122. Online calculator
- ↑ Labrie F, Candas B, Dupont A; et al. (1999). "Screening decreases prostate cancer death: first analysis of the 1988 Quebec prospective randomized controlled trial". Prostate. 38 (2): 83–91. PMID 9973093.
- ↑ Schröder F, Raaijmakers R, Postma R, van der Kwast T, Roobol M (2005). "4-year prostate specific antigen progression and diagnosis of prostate cancer in the European Randomized Study of Screening for Prostate Cancer, section Rotterdam". J Urol. 174 (2): 489–94, discussion 493-4. PMID 16006878.
- ↑ Krahn MD, Mahoney JE, Eckman MH, Trachtenberg J, Pauker SG, Detsky AS (1994). "Screening for prostate cancer. A decision analytic view". JAMA. 272 (10): 773–80. PMID 7521400.
- ↑ 23.0 23.1 Ross KS, Carter HB, Pearson JD, Guess HA (2000). "Comparative efficiency of prostate-specific antigen screening strategies for prostate cancer detection". JAMA. 284 (11): 1399–405. PMID 10989402.
- ↑ U.S. Preventive Services Task Force (2002). "Screening for prostate cancer: recommendation and rationale". Ann. Intern. Med. 137 (11): 915–6. PMID 12458992.
- ↑ Harris R, Lohr KN (2002). "Screening for prostate cancer: an update of the evidence for the U.S. Preventive Services Task Force". Ann. Intern. Med. 137 (11): 917–29. PMID 12458993.
- ↑ U.S. Preventive Services Task Force (December 2002)). "Screening for Prostate Cancer". Retrieved 2006-09-14. Check date values in:
|date=(help) - ↑ Smith RA, von Eschenbach AC, Wender R; et al. (2001). "American Cancer Society guidelines for the early detection of cancer: update of early detection guidelines for prostate, colorectal, and endometrial cancers. Also: update 2001--testing for early lung cancer detection". CA: a cancer journal for clinicians. 51 (1): 38–75, quiz 77-80. PMID 11577479.
- ↑ National Guideline Clearinghouse. "Recommendations from the American Cancer Society Workshop on Early Prostate Cancer Detection". Retrieved 2006-09-14.
- ↑ American Cancer Society. "What the American Cancer Society Recommends". Retrieved 2007-01-16.