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Prostate Cancer Screening

Prostate Cancer Screening

Prostate Cancer ScreeningProstate cancer screening involves two routine tests to determine whether a man who currently has no symptoms of prostate cancer has clinical signs of the disease.

The two tests used for prostate cancer screening are simple and easily accessible: the digital rectal examination (DRE) and a blood test called the prostate specific antigen (PSA) test.

If the screening tests are so simple, why don’t men just routinely get screened? The reason is that both the DRE and PSA test are not perfect, and there are benefits and risks associated with having the tests.

Benefits of Prostate Cancer Screening

On the upside, prostate cancer that is detected early can usually be treated more effectively. Also, prostate cancer that is caught at an early stage allows men to choose from more treatment options. Early prostate cancer screening may also provide peace of mind to men who want to do all they can to prevent or, if cancer is discovered, aggressively treat the situation.

Risks/Downside of Prostate Cancer Screening

On the downside, there is evidence that treating prostate cancer detected by screening causes moderate to substantial negative effects, including erectile dysfunction, urinary incontinence, bowel dysfunction, and death. These harmful effects are important because some men who have prostate cancer who are treated would never have developed cancer-related symptoms during their lifetime. There is also evidence that the screening process produces pain and discomfort associated with undergoing a prostate biopsy and emotional harm related to false-positive test results (when test results say you have the disease, but you really don’t).

Guidelines for Prostate Cancer Screening

American Cancer Society

The American Cancer Society (ACS) has issued the following guidelines for prostate cancer screening, which were updated in March 2010:

  • Starting at age 50, men who are at average risk of prostate cancer and who are expected to live at least 10 more years should talk to their doctor about the pros and cons of testing to decide if screening is right for them. The ACS notes that for men who have a life expectancy of less than 10 years, the harms outweigh the benefits of prostate cancer screening.
  • African-American men and all men who are at high risk (have a first-degree relative—father, brother, son–who had prostate cancer before age 65) should talk to their doctor starting at age 45.
  • Men at even higher risk (those with several first-degree relatives who had prostate cancer at an early age) should talk to their doctor starting at age 40

There were two basic changes in the March 2010 guidelines. One was that there are mixed conclusions about whether prostate cancer screening can save lives. The American Cancer Society states that men who are eligible for the PSA need to know that although prostate cancer screening “may be associated with a reduction in the risk of dying from prostate cancer…evidence is conflicting and experts disagree about the value of screening.”

The second change concerns the idea of shared or informed decision making. It stresses that men should be fully informed about the benefits and risks of early prostate cancer screening with their healthcare provider, and that men should consider their own values in the decision making process.

Men who cannot decide if testing is right for them can allow their healthcare provider to make that decision. The healthcare provider should consider the patient’s general health, preferences, and values.

Men who choose to be screened should have a blood sample taken for the PSA, followed by the digital rectal exam. If their PSA results are less than 2.5 ng/ml, they can be retested every two years. If the test results are greater than 2.5 ng/ml, screening should be done yearly. When a PSA is greater than 4.0 ng/ml, it is reasonable for men to consider a prostate biopsy.

When deciding whether prostate cancer screening is right for them, men need to consider their overall health status and not age alone. That’s because prostate cancer grows slowly, and men without symptoms of prostate cancer who do not have a ten-year life expectancy do not need screening because they are not likely to benefit from it.

Once men make a decision about screening, they should have a new discussion with their healthcare provider when new information about the benefits and risks of testing becomes available. The question of screening should also be readdressed whenever there are changes in a man’s health, values, and preferences.

American Urological Association

In May 2013, the American Urological Association (AUA) updated its 2009 Best Practice Statement on Prostate-Specific Antigen (PSA). These guidelines differ significantly from their past statements. The AUA’s new guidelines are as follows:

  • Men aged 55–69 who are thinking about PSA screening should discuss the benefits and harms of screening with their healthcare provider as part of the decision-making process and proceed based on their personal values and preferences.
  • The AUA does not recommend screening for men under 40.
  • Routine PSA screening is not recommended for men of average risk between the ages of 40 and 54.
  • Routine screening is not recommended for men over 70.
  • The AUA does not recommend screening for any man who has a life expectancy of less than 10–15 years.
  • For men who have gone through the decision-making process and decide to get routine screening, spacing screenings to every two years or more is preferable to annual screening to reduce the harms of screening. Screening every two years may preserve the benefits of screening while decreasing false positives and overdiagnosis.
  • Other factors such as family history, age, overall health, and ethnicity should be considered along with the results of the PSA and physical examination to better determine the risk of prostate cancer
  • The Association does not recommend a single PSA threshold at which a biopsy should be obtained. The decision to biopsy should take into account factors such as free and total PSA, PSA velocity and density, patient age, family history, race/ethnicity, previous biopsy history, and presence of other health conditions.

According to the AUA, “the highest-quality evidence for screening benefit (lower PCa mortality) was for men aged 55–69 years screened at two-to four-year intervals.” The panel that developed these guidelines said that ongoing research, for example studies on biomarkers besides PSA, might lead to future guideline changes.

Memorial Sloan-Kettering Cancer Center

Memorial Sloan-Kettering’s guidelines for prostate cancer screening are based on the following principles:

  1. Many men with prostate cancer do not need to be treated: A diagnosis of prostate cancer is information used to help make decisions, not an indication for immediate treatment.
  2. Compliance with screening will increase if men are told whether they are at high, intermediate, or low risk and are informed accordingly about their need for subsequent screening.
  3. There is a balance between the harms and benefits of screening: The ratio between benefits and harms will be maximized if screening focuses on men at highest risk of life-threatening prostate cancer.

Memorial Sloan-Kettering’s doctors recommend the following screening guidelines:

  1. All men should receive a PSA test at age 45. For these men with a:
    1. PSA greater than or equal to 3 ng / mL: Consider biopsy
    2. PSA greater than 1 but less than 3 ng / mL: Return for PSA every two years
    3. PSA from 0.65 to 1 ng / mL: Return for PSA at age 50
    4. PSA less than 0.65 ng / mL: Return for PSA at age 55
  2. For men aged 45 to 59 with a:
    1. PSA greater than or equal to 3 ng / mL: Consider biopsy
    2. PSA greater than 1 but less than 3 ng / mL: Return for PSA every two years
    3. PSA from 0.65 to 1 ng / mL: Return for PSA in five years, or age 60 if age > 55
    4. PSA less than 0.65 ng / mL: Return for PSA at age 60
  3. For men aged 60 to 70 with a:
    1. PSA greater than or equal to 3 ng / mL: Consider biopsy
    2. PSA greater than 1 but less than 3 ng / mL: Return for PSA every two years
    3. PSA less than or equal to 1 ng / mL: No further screening
  4. For men aged 71 or older:
      1. No further screening

    Patients should be informed of their risk. A 50 year-old man with a PSA of 2 ng / mL has a much higher risk of a subsequent life-threatening prostate cancer than a man of similar age who has a PSA of 0.4 ng / mL. The current approach, to inform both men that “PSA results were negative” and that they should return for regular testing, leads to imperfect compliance. Instead, the man with the PSA of 2 ng / mL should be informed that, although he may not need an immediate biopsy, he is in a high-risk category, and he should have his PSA checked regularly so that, were he to develop prostate cancer, it would be diagnosed early. The man with the low PSA, on the other hand, can be reassured that he is at low risk and does not need further PSA testing for many years (e.g., a repeat PSA testing at age 55 or 60).

    Guidelines should be individualized. The guidelines should be modified to deal with individual patients. A patient with a strong family history of prostate cancer might reasonably be considered for a PSA test at age 40. Conversely, a man recently diagnosed with a life-threatening heart condition might be advised against subsequent PSA screening. Similarly, intensity of screening can be individualized within risk groups. As an example, the recommendation is for screening every two years for men with a PSA of 1 to 3 ng / mL. A physician may choose to recommend a four-year interval for an older man with a PSA close to 1 ng / mL, or an interval of less than two years for a younger man with a PSA close to 3 ng / mL.

    Go to the Memorial Sloan-Kettering Website for more information

    US Preventive Services Task Force

    The recommendations of the US Preventive Services Task Force (USPSTF) are followed by the Centers for Disease Control and Prevention and other federal agencies. In May 2012, the USPSTF revised its recommendations regarding prostate cancer screening, stating that it did not recommend PSA testing for men of any age because it believed the risks outweigh the benefits. Specifically, the USPSTF noted that use of the PSA test results in the over-diagnosis of prostate cancer, which can then lead to unnecessary prostate biopsies and treatment for prostate cancer in men who are at low to no risk of dying of the disease. Prior to this new recommendation, the USPSTF had recommended that healthcare providers not order the PSA test without first discussing with the patient the uncertain benefits and the recognized negative effects associated with prostate cancer screening and treatment. The Task Force had also recommended against prostate cancer screening in men 75 years and older.

    Prostate Cancer Screening in Other Countries

    In the United Kingdom, there is no organized prostate cancer screening program, but there is an informed choice program, Prostate Cancer Risk Management. The purpose of this program is to ensure that men who are concerned about prostate cancer receive comprehensive, balance information about the benefits and risks of the PSA test and treatment options for prostate cancer. This will help men decide whether they want to have the test.

    In Australia, no prostate cancer screening program exists. The position of the Australian Health Ministers’ Advisory Council, supported by the Cancer Council Australia and the Screening Subcommittee of the Australian Population Health Development Principal Committee, is that men who are considering prostate cancer screening should discuss the benefits and risks with their healthcare provider.

    The Australian organizations believe the current evidence demonstrates that the harms (e.g., erectile dysfunction, urinary incontinence, bowel problems) of such screening using the PSA test outweigh the benefits, and therefore either alone or combined with DRE, the PSA test does not form the basis of a population-based screening program. More specifically, they find the PSA test to be unreliable for screening purposes, as PSA levels can rise due to benign causes, and levels can also be low in men who have prostate cancer. Regarding DRE, its effectiveness is limited because portions of the prostate cannot be felt and small tumors may be undetectable.

    See also

    The Prostate Test, It’s No Laughing Matter

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Created: August 30, 2010
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Site last updated 20 April, 2014

  
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