Prostate Cancer Screening

We recently had a vigorous discussion of Prostate Cancer Screening in clinic. There is certainly a lot to think about.

Prostate Cancer Screening Guidelines from the American Cancer Society (AFP review):

• PSA & DRE annually at age 50 in men with life expectancy at least 10 years
  • "Men who ask their physician to make the decision for them should be tested."  
  • "Men who request screening tests at an earlier age should not be discourage from testing."  
• High risk - begin testing at age 45
  • men of sub-Saharan African descent
  • first degree relative with disease diagnosed before age 65 
  • ... if >1 first degree relatives, begin screening at age 40  
    • PSA <1ng/mL no additional testing until age 45 
    • PSA >1ng/mL (<2.5ng/mL) then annual testing
    • PSA >2.5ng/mL, then further evaluation with biopsy 

Similar guidelines can be seen from the American Urological Association and the National Comprehensive Cancer Network. The "NCCN Clinical Practice Guidelines in Oncology: Prostate Cancer Early Detection" is a wonderful repository of algorithms for the early detection of prostate cancer, and what to do with a variety of abnormal PSA results.

Finally, the USPTF (see below) has updated their longstanding guidelines, now recommending against prostate cancer screening in men over the age of 75. For the longest time, they've stated that the evidence is inconclusive to recommend for or against screening.

In interpreting this discrepancy for my clinical practice, I found the following letter to the editor ("a more nuanced approach to prostate cancer screening") helpful.

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Clinical Guidelines:
U.S. Preventive Services Task Force

Screening for Prostate Cancer: U.S. Preventive Services Task Force Recommendation Statement
Ann Intern Med 2008; 149: 185-191 5 August 2008 [Abstract] [Full text] [PDF]

Description: Update of the 2002 U.S. Preventive Services Task Force (USPSTF) recommendation statement about screening for prostate cancer.

Methods: The USPSTF evaluated randomized, controlled trials of the benefits of prostate cancer screening; cohort and cross-sectional studies of the psychological harms of false-positive prostate-specific antigen test results; and evidence on the natural history of prostate-specific antigen–detected prostate cancer to address previously identified gaps in the evidence from the 2002 USPSTF recommendation.

Recommendations: 

• Current evidence is insufficient to assess the balance of benefits and harms of screening for prostate cancer in men younger than age 75 years (I statement).

• Do not screen for prostate cancer in men age 75 years or older (Grade D recommendation).

Summaries for Patients 
Screening for Prostate Cancer with Prostate-Specific Antigen Testing: U.S. Preventive Services Task Force Recommendations

Annals 2008 149: I-37. [Full Text]