Prostate Cancer Screening

 


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Am Fam Physician. 2015 Oct 15;92(8):683-688.

  Related editorial: Prostate Cancer Screening: The Pendulum Has Swung, and the Burden of Proof Is with Proponents

  Related Medicine by the Numbers: PSA Screening for Prostate Cancer

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  Patient information: A handout on this topic is available at http://familydoctor.org/familydoctor/en/diseases-conditions/prostate-cancer/diagnosis-tests/pros---cons-of-psa-testing-.html.

Author disclosure: No relevant financial affiliations.

Among American men, prostate cancer is the most commonly diagnosed cancer and the second leading cause of cancer-related death. Although prostate-specific antigen (PSA) testing has been used to screen for prostate cancer for more than 25 years, the test has low sensitivity and specificity, and there is no clear evidence for determining what threshold warrants prostate biopsy. Only one of five randomized controlled trials of PSA screening showed an effect on prostate cancer–specific mortality, and the absolute reduction in deaths from prostate cancer was one per 781 men screened after 13 years of follow-up. None of the trials showed benefit in all-cause mortality, and screening increased prostate cancer diagnoses by about 60%. Harms of screening include adverse effects from prostate biopsy, overdiagnosis and overtreatment, and anxiety. One-half of screen-detected prostate cancers will not cause symptoms in the patient's lifetime, and 80% to 85% of men who choose observation will not die from prostate cancer within 15 years. Adverse effects of radical prostatectomy include perioperative complications, erectile dysfunction, and urinary incontinence. Radiation therapy can cause acute toxicity leading to urinary urgency, dysuria, diarrhea, and rectal pain; late toxicity includes erectile dysfunction, rectal bleeding, and urethral stricture. Despite variations across guidelines, no organization recommends routine PSA testing, and all endorse some form of shared decision-making before testing. If screening is performed, it should generally be discontinued at 70 years of age.

In 2014, about 233,000 American men were diagnosed with prostate cancer, and almost 33,000 died from it.1 Approximately one in six men (16.7%) will be diagnosed with prostate cancer during his lifetime, but less than 3% will die from the disease. Prostate cancer mainly affects older men; 60% of cases are diagnosed after 65 years of age, and 70% of men who die from prostate cancer are 75 years or older.2

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationsEvidence ratingReferences

The U.S. Preventive Services Task Force and American Academy of Family Physicians recommend against prostate-specific antigen testing to screen for prostate cancer because the harms outweigh the benefits in most men.

B

31, 32

Physicians should inform patients about the harms and benefits of prostate-specific antigen testing and use shared decision making. Only men who express a clear preference for screening should be tested.

C

10, 36, 37

Prostate cancer screening should not be performed in men younger than 50 years or older than 70 years, or in men with a life expectancy of less than 10 to 15 years.

C

10, 31, 32, 36, 37


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationsEvidence ratingReferences

The U.S. Preventive Services Task Force and American Academy of Family Physicians recommend against prostate-specific antigen testing to screen for prostate cancer because the harms outweigh the benefits in most men.

B

31, 32

Physicians should inform patients about the harms and benefits of prostate-specific antigen testing and use shared decision making. Only men who express a clear preference for screening should be tested.

C

10, 36, 37

Prostate cancer screening should not be performed in men younger than 50 years or older than 70 years, or in men with a life expectancy of less than 10 to 15 years.

C

10, 31, 32, 36, 37


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

View/Print Table

BEST PRACTICES IN UROLOGY: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

RecommendationSponsoring organization

Do not routinely screen for prostate cancer using a PSA test or digital rectal examination.

American Academy of Family Physicians

Do not routinely perform PSA-based screening for prostate cancer.

American College of Preventive Medicine

Do not recommend screening for prostate cancer (with the PSA test) without considering life expectancy and the risks of testing, overdiagnosis, and overtreatment.

American Geriatrics Society

Do not perform PSA testing for prostate cancer screening in men with no symptoms of the disease when they are expected to live less than 10 years.

American Society of Clinical Oncology

Offer PSA screening for prostate cancer only after engaging in shared decision making.

American Urological Association


PSA = prostate-specific antigen.

Source: For more information on the Choosing Wisely Campaign, see http://www.choosingwisely.org

The Authors

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ELIE MULHEM, MD, is vice chair for research and women's health at Oakland University William Beaumont School of Medicine, Sterling Heights, Mich....

NIKOLAUS FULBRIGHT, MD, is a faculty physician in the Department of Family Medicine at Providence Hospital, South Lyon, Mich.

NORAH DUNCAN, MD, is a resident physician in the Department of Family Medicine at Oakland University William Beaumont School of Medicine.

Address correspondence to Elie Mulhem, MD, Oakland University William Beaumont School of Medicine, 44250 Dequindre Rd., Sterling Heights, MI 48314 (e-mail: emulhem@beaumont.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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