Prostate Cancer

PSA-Based Prostate Cancer Screening in Men Aged 55-69

Grade: C recommendation

The AAFP does not recommend routine prostate-specific antigen (PSA)-based screening for prostate cancer. For men aged 55 through 69 who are considering periodic prostate cancer screening, clinicians should discuss the risks and benefits and engage in shared decision-making that enables an informed choice.

Screening for prostate cancer using PSA may prevent mortality from prostate cancer for a small number of men, while putting many men at risk for long term harms, such as urinary incontinence and erectile dysfunction.  Whether this potentially small benefit in mortality outweighs the potential harms is dependent on the values and preferences of individual men.  Therefore, for men who express a desire for prostate cancer screening, it should only be performed following a discussion of the potential benefits and harms. Routine screening for prostate cancer should not be done. See Clinical Considerations for more information.

Grade Definition

Prostate Cancer Screening in Men Aged 70 and Older

Grade: D recommendation

The AAFP recommends against screening for prostate cancer in men aged 70 and older.

Men aged 70 years and older have a higher rate of prostate cancer, but because they are more likely to die from a cause other than their prostate cancer, the potential benefit screening is diminished.  Older men experience more harms from screening, including increased rates of false positives, overdiagnosis, and increased risk of harms from biopsy and treatment. For these reasons, prostate cancer screening should not be done in men aged 70 years and older.

Grade Definition

Clinical and Implementation Considerations for Men Aged 55-69

Screening for prostate cancer using PSA may prevent mortality from prostate cancer for a small number of men, while putting many men at risk for long term harms, such as urinary incontinence and erectile dysfunction.  Whether this potentially small benefit in mortality outweighs the potential harms is dependent on the values and preferences of individual men.  Therefore, for men who express a desire for prostate cancer screening, it should only be performed following a discussion of the potential benefits and harms. Routine screening for prostate cancer should not be done.

Benefits and Harms of Screening

Based on results of one major trial on screening (ERSPC) and three clinical trials examining treatment, it is estimated that after 13 years, of 1,000 men screened for prostate cancer, 100 will be diagnosed with prostate cancer.  As the result of early treatment, 1.3 men will avoid dying of prostate cancer, while 5 men will die of prostate cancer despite treatment. It is also estimated that screening will result in three fewer cases of metastatic prostate cancer. While the mortality benefit of prostate cancer screening is the result of early treatment, the treatment of prostate cancer causes the most serious harms (Table 1). These potential harms are particularly concerning given the high rate of overdiagnosis associated with prostate cancer screening.  Overdiagnosis involves the diagnosis of asymptomatic cancer that never would have resulted in symptoms or death.  The exact rate of overdiagnosis is impossible to determine, but it is estimated to be as high as 50% for prostate cancer screening. This means that up to half of men exposed to the harms of treatment would never have been affected by their cancer.

Men at High Risk for Prostate Cancer

It is unclear which men may benefit from prostate cancer screening.  There is insufficient evidence to determine whether men at increased risk for prostate cancer are more likely to benefit from screening or are more likely to experience harms compared to the general population.  African American men have a higher rate of prostate cancer and a higher mortality rate from prostate cancer, but there is not sufficient data in this population to recommend routine screening or a different screening strategy.  Men with a family history of prostate cancer are also at a higher risk. However, limited data does not support an additional mortality benefit of screening in these men. At this time, the evidence is insufficient for the AAFP to make a screening recommendation specific to men at increased risk for prostate cancer. Due to the lack of evidence in these populations, African American men and men with a family history of prostate cancer should be informed of their increased risk of developing prostate cancer in addition to the benefits and harms of screening so that they may make an informed choice.

Screening Intervals and Thresholds

The studies of prostate cancer screening used different screening intervals and different PSA thresholds.  The ideal screening strategy has not been determined, but single screens were not shown to be effective.  For men who choose to undergo screening for prostate cancer, they should not be screened more frequently than every 2 years.  A PSA level of 4.0 ng/mL is a commonly used cutoff, but thresholds vary.  Lower thresholds will result in higher rates of false positives, overdiagnosis, and associated harms, while higher thresholds may minimize harms but potentially lower the mortality benefit.  Digital Rectal Exam does not improve detection of prostate cancer and should not be performed as a part of screening.

Table 1: Estimated Effects of PSA-based screening for prostate cancer in men aged 55-69 years after 13 years