Am Fam Physician. 2014 Jan 15;89(2):137.
Guideline source: American Urological Association
Evidence rating system used? Yes
Literature search described? Yes
Guideline developed by participants without relevant financial ties to industry? No
Available at: http://www.auanet.org/common/pdf/education/clinical-guidance/Prostate-Cancer-Detection.pdf [subscription required]
In April 2013, the American Urological Association (AUA) released a guideline on early detection of prostate cancer, namely to reduce prostate cancer mortality.
YOUNGER THAN 40 YEARS
The prevalence of prostate cancer in men younger than 40 years is very low, and even if cancer is found in men this age, the disease is of low volume and low Gleason grade. No prospective randomized trials assessing the benefits of prostate-specific antigen (PSA) testing included men younger than 40 years; therefore, there is no information to determine benefit in this population. Harms, however, include adverse effects of biopsies and possibly treatment. For these reasons, the AUA recommends against PSA screening in men in this age group.
40 TO 54 YEARS OF AGE
There is no high-quality evidence to support routine screening in men 40 to 54 years of age, assuming these men are not at increased risk of prostate cancer (e.g., family history, black). Therefore, the AUA does not recommend routine screening in this population. It should be noted that this recommendation is not meant to suggest that there is no benefit from screening, but rather that the harms associated with screening are substantial enough that they likely outweigh the benefits.
55 TO 69 YEARS OF AGE
To make a decision about PSA screening, physicians should weigh the benefits of preventing mortality in one man for every 1,000 screened over 10 years against the possible harms of screening and treatment. Therefore, the AUA strongly recommends shared decision making in men 55 to 69 years of age who are considering PSA screening, with the decision being based on the patient's values and preferences. The patient's life expectancy should be included in the discussion of benefits and harms. Baseline mortality risk from other conditions, risk of prostate cancer, and the level to which screening may impact life expectancy and risk of morbidity from prostate cancer or treatment should also be discussed. The AUA indicates that the benefits of screening likely outweigh harms in this population, justifying the recommendation for shared decision making.
In men who have participated in shared decision making and have chosen to undergo screening, a screening interval of at least two years may be preferred over screening every year. Although randomized controlled trials have used two- and four-year screening intervals, a specific interval has not been determined. Estimates from modeling studies indicate that, compared with annual screening, biennial screening preserves most of the benefits of screening, while reducing the number of tests, the risk of false-positive results, and overdiagnosis.
70 YEARS AND OLDER
The AUA does not recommend routine PSA screening in men 70 years and older, or in men with a life expectancy less than 10 to 15 years. This recommendation is based on the lack of evidence of benefit in this population, and on the clear evidence of harms. Although men 70 years and older can have a life expectancy of more than 10 to 15 years, and some men in this age group are in excellent health and may benefit from screening, data to indicate overall benefit in this population are limited. Shared decision making and consideration of individual values, preferences, and quality of life goals are vital.
Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.
A collection of Practice Guidelines published in AFP is available at http://www.aafp.org/afp/practguide.
Copyright © 2014 by the American Academy of Family Physicians.
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