PUTTING PREVENTION INTO PRACTICE: AN EVIDENCE-BASED APPROACH
Screening for Prostate Cancer
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Am Fam Physician. 2004 Apr 1;69(7):1721-1722.
This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). EB CME is clinical content presented with practice recommendations supported by evidence that has been systematically reviewed by an AAFP-approved source. The practice recommendations in this activity are available at http://www.ahrq.gov/clinic/uspstf/uspsprca.htm.
DS, a 55-year-old African-American man, comes into your office for a physical examination. While talking about his family history, you learn that his father had prostate cancer. DS asks if he should be tested for prostate cancer. Before counseling him, you review the U.S. Preventive Services Task Force (USPSTF) recommendations on prostate cancer screening.
Case Study Questions
1. Which one of the following statements about prostate cancer is correct?
A. Prostate cancer is the fourth leading cause of cancer-related death among men.
B. The risk of prostate cancer increases beginning at age 50.
C. Prostate cancer incidence and mortality rates are the same in African-American men and white men.
D. Hispanic men have slightly higher mortality rates from prostate cancer than white men do.
E. Many more men are diagnosed with prostate cancer than die of it.
2. Which one of the following statements regarding the USPSTF routine prostate cancer screening recommendations is correct?
A. The USPSTF recommends routine prostate cancer screening for men age 40 and older.
B. The USPSTF does not recommend for or against routine prostate cancer screening.
C. The USPSTF recommends routine prostate cancer screening for men age 50 and older.
D. The USPSTF recommends routine prostate cancer screening for men age 40 and older who are at high risk for prostate cancer.
E. The USPSTF recommends routine prostate cancer screening for men age 50 and older who are at high risk for prostate cancer.
3. In counseling DS, you discuss the effectiveness of screening for prostate cancer using digital rectal examination (DRE) and prostate-specific antigen (PSA) testing. Which of the following statements about screening is/are correct?
A. Screening can effectively detect prostate cancer in its early pathologic stages.
B. Detection of prostate cancer by screening leads to improved outcomes.
C. All cancers detected by screening will be clinically significant over a patient's lifetime.
D. The yield of screening in terms of cancers detected decreases with repeated annual testing.
1. The correct answer is E. Many more men are diagnosed with prostate cancer than die of it. Men in the United States have a 15 percent lifetime risk of being diagnosed with prostate cancer but only a 3 percent lifetime risk of dying of the disease. However, prostate cancer is the second leading cause of cancer-related death among U.S. men. In 2002, an estimated 30,200 men died of prostate cancer. The risk of developing prostate cancer increases beginning at age 40, and the burden of prostate cancer varies among different racial and ethnic groups. African-American men have about a 60 percent higher incidence and a twofold higher mortality rate from prostate cancer compared with white men. Non-white Hispanics have a 35 percent lower mortality rate than white men, and Asian-Americans and Pacific Islanders have a 40 percent lower rate.
2. The correct answer is B. The USPSTF concludes that the evidence is insufficient to recommend for or against routine prostate cancer screening. The balance of potential benefits (i.e., the reduction of prostate cancer morbidity and mortality) and harms (e.g., false-positive results, unnecessary biopsies, possible complications) of early treatment remains uncertain. Despite the absence of firm evidence, some clinicians may opt to perform prostate cancer screening for other reasons. If early detection is shown to improve health outcomes, screening will most likely benefit average-risk men aged 50 to 70 and men older than 45 who are at increased risk (e.g., men with a first-degree relative with prostate cancer, African-American men). Older men and men with significant medical problems who have a future life expectancy of fewer than 10 years are unlikely to benefit from screening. Given the uncertainties and controversy surrounding prostate cancer screening, clinicians should not order the PSA test without first discussing the potential benefits and harms of screening with their patients.
3. The correct answers are A and D. Screening with DRE and PSA testing can effectively detect prostate cancer in its early pathologic stages, but the extent to which earlier detection leads to improved outcomes is uncertain. Screening with DRE and PSA testing may detect cancers that appear clinically significant based on size and grade but which would not have progressed to clinical symptoms during a patient's lifetime. The yield of screening in terms of cancers detected declines rapidly with repeated annual testing.
U.S. Preventive Services Task Force. Screening for prostate cancer: recommendations and rationale. Accessed March 19, 2004 at: http://www.ahrq.gov/clinic/3rduspstf/prostatescr/prostaterr.htm.
Harris R, Lohr KN. Screening for prostate cancer: an update of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;137:917–29.
Harris R, Lohr KN, Beck R, Fink K, Godley P, Bunton AJ. Screening for prostate cancer. Systematic evidence review no. 16 (Prepared by the Research Triangle Institute—University of North Carolina Evidence-based Practice Center under Contract No. 290-97-0011). Rockville, Md.: Agency for Healthcare Research and Quality, 2001. Accessed March 19, 2004 at: http://www.ahrq.gov/clinic/prev/prostinv.htm.
The case study and answers to the following questions on screening prostate cancer are based on the recommendations of the U.S. Preventive Services Task Force (USPSTF), part of the Put Prevention into Practice program of the Agency for Healthcare Research and Quality (AHRQ). This recommendation was released in 2002 and is an update of the 1996 recommendation on screening for prostate cancer. More detailed information on this subject is available in the USPSTF Recommendations and Rationale, the summary of the evidence, and the systematic evidence review on the USPSTF Web site (http://www.ahrq.gov/clinic/uspstfix.htm). The summary of the evidence and recommendation statement are available in print by subscription through the AHRQ Publications Clearinghouse (800-358-9295, e-mail, email@example.com).
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