Prostate Cancer Screening in Asymptomatic Men | Epocrates Guideline Synthesis

  • AAFP, USPSTF don’t recommend PSA screens.
  • Shared decision making emphasized.
  • Biomarkers to improve specificity not recommended as 1st-line screen.
  • Don’t screen if life expectancy <10 yrs.
  • Varied guidance on whether African American, FHx warrants lower age thresholds.

    Choose Patient Type
  •         <40 yo, life expectancy ≥10 yrs
  •         40-49 yo, life expectancy ≥10 yrs
  •         50-69 yo, life expectancy ≥10 yrs
  •         ≥70 yo or life expectancy <10 yrs


    *<40 yo, life expectancy =/> 10 yrs
  •    Don’t screen for prostate CA
  •      Screening not recommended by ACP1
  •      AUA2 recommends against PSA screening <40 yo
  •      AAFP3 and USPSTF4 don’t recommend PSA screening asymptomatic men at any age

    Footnotes
       1 ACP 2013. Screening for Prostate Cancer: A Guidance Statement From the Clinical Guidelines Committee of the   
          American College of Physicians. Amir Qaseem, et al. Ann Intern Med. 2013;158(10):761-769. PDF

       2 [AUA-R/C] AUA 2013. If <55 yo at higher risk (eg, (+) FHx or African American), decisions should be individualized; this
          doesn’t imply absolutely no benefit, rather that significant harms associated w/ screening are such that benefits are
          likely not great enough to outweigh the harms. Early Detection of Prostate Cancer: AUA Guideline. H Ballentine Carter,
          et al. PDF

       3 [AAFP-D] AAFP 2012. Clinical Preventive Service Recommendation, Prostate Cancer. Online Accessed 12/8/15.

       4 [USPSTF-D] USPSTF 2012 (update in progress). Convincing evidence that PSA-based screening detects many
           prostate CA cases, a substantial % w/ asymptomatic CA detected by PSA have a tumor that won’t progress—or will
           progress so slowly that it would’ve remained asymptomatic for a lifetime. Reduction in prostate CA mortality 10-14 yrs
           after PSA-based screening is very small, even for men in optimal age range of 55-69 yo. Prostate Cancer: Screening.
           PDF
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    * 40-49 yo, life expectancy =/> 10 yrs
  • High-risk (race/FHx/genes): Some recommend discussion w/ shared decision-making in light of
    uncertainties/risks1,2/benefits;3 if pt desires4 screen, use PSA5,6 (may include DRE)7
  • 40+ yo if ≥1 1st-deg relative w/ early-age (<65 yo) prostate CA, per ACP,8 ACS.4 If BRCA mutation: Discussion
    starting 40 yo, per NCCN5
  • 45+ yo if African American or 1st-deg relative w/ early-age (<65 yo) prostate CA, per ACP,8 ACS,4 while AUA9
    recommends individualized decisions for this group
  • Rescreen interval guidance varies by age, PSA level, per ACP,10 AUA,11 NCCN12
  • ASCO:13 No evidence that higher-prevalence groups have different degrees of benefit/risk w/ PSA screening
    vs general population
  • AAFP14 and USPSTF15 don’t recommend PSA screening
  • Average-risk: Screening not recommended by most groups
  • Screening not recommended by AUA,9 ACP16
  • AAFP14 and USPSTF15 don’t recommend PSA screening asymptomatic men at any age
  • NCCN:5,12 45+ yo, recommend starting risk/benefit screening discussion about baseline PSA (consider
    DRE)7

    Footnotes
    1 ACS 2015. Risks: Age - (Rare <50 yo). Race - Higher in African Americans, Caribbeans of African ancestry; lower risk in Asian
    Americans, Hispanics/Latinos vs non-Hispanic whites. FHx - Risk higher w/ brother vs father; much higher if several affected
    relatives, esp if young when CA found. Genetic risks - BRCA1 or BRCA2, Lynch/HNPCC syndrome. Diet - High red meat or high-
    fat dairy appear slightly higher risk; these men also tend to eat fewer fruits + vegetables. Firefighters exposed to toxic substances
    may have increased risk. Obesity not found linked to overall risk, nor has smoking. Prostatitis, STD, vasectomy studies conflicting.
    Prostate Cancer Prevention and Early Detection. Online Accessed 12/8/15.

    2 NCI 2015. Harms: Screening can have adverse psychological effects. Prostatic bx are associated with complications, including
    fever, pain, hematospermia/hematuria, (+) urine Cx, sepsis. Per solid evidence, screening w/ PSA and/or DRE detects some
    prostate cancers that would’ve never caused important clinical problems, hence leads to some degree of over-tx. Per solid
    evidence, current prostate CA tx, including radical prostatectomy and radiation tx, result in permanent side effects in many men.
    Most common are erectile dysfunction and urinary incontinence: 20%-70% who had no problems before radical prostatectomy or
    external-beam radiation tx will have reduced sexual function and/or urinary problems. Prostate Cancer Screening–for health
    professionals (PDQ). Online Accessed 12/8/15.

    3 NCI 2015. Benefits: Evidence insufficient to determine whether screening w/ PSA or DRE reduces prostate-CA mortality.
    Screening can detect prostate CA at an early stage, but it’s not clear whether earlier detection/tx changes natural history and
    outcomes. Prostate Cancer Screening–for health professionals (PDQ). Online Accessed 12/8/15.

    4 ACS 2014. If pt can’t decide, clinician decides based on pt values, health status. Prostate Cancer Prevention and Early
    Detection. PDF

    5 [NCCN-2A]
    NCCN 2015. Best evidence supports serum PSA for early detection. No recommendations for race-specific PSA ranges.
    Biomarkers that improve detection specificity not recommended for 1st-line screening. In pts w/ PSA >3 ng/mL who’ve not yet had
    a bx, NCCN recommends considering percent free PSA (%f PSA), 4Kscore, Prostate Health Index (phi). Online Accessed 12/8/15.

    6 ACS 2015. PSA levels ↑ w/ BPH, older age, prostatitis, ejaculation, bicycling, urologic procedures (bx, cystoscopy), certain
    medicines (eg, testosterone), DRE (per some studies). PSA ↓ w/ 5-alpha-reductase inhibitors finasteride (Proscar or Propecia) or
    dutasteride (Avodart), some herb mixes (not saw palmetto), obesity, regular aspirin, statins (not if calcium channel blockers also
    taken), thiazide diuretics (thiazide + statin synergistically lower). Prostate Cancer Prevention and Early Detection. Online
    Accessed 12/8/15.

    7 NCI 2015. DRE might raise PSA levels slightly, per some, but not all, studies. Prostate Cancer Screening–for health
    professionals (PDQ). Online Accessed 12/8/15.

    8 ACP 2013. Outcomes for screening high-risk men not demonstrated to be different vs screening average-risk men. Amir
    Qaseem, et al. Screening for Prostate Cancer: A Guidance Statement From the Clinical Guidelines Committee of the American
    College of Physicians. Ann Intern Med. 2013;158(10):761-769. PDF

    9 [AUA-R/C]
    AUA 2013. If <55 yo at higher risk (eg, (+) FHx or African American), decisions should be individualized; this doesn’t imply
    absolutely no benefit, rather that significant harms assoc w/ screening are such that benefits are likely not great enough to
    outweigh harms. Early Detection of Prostate Cancer: AUA Guideline. H Ballentine Carter, et al. PDF

    10 ACP 2013. No clear evidence that screening more often than q4yrs offers additional benefit; annual screening in PLCO trial
    found no benefit. PSA ≥2.5 µg/L may warrant annual eval. Amir Qaseem, et al. Screening for Prostate Cancer: A Guidance
    Statement From the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2013;158(10):761-
    769. PDF

    11 [AUA-O/C]
    AUA 2013. Routine screening interval 2 yrs or more preferred vs annually; intervals can be individualized per baseline PSA.
    Evidence suggests annual screening not likely to produce significant incremental benefits vs q2yrs. Early Detection of Prostate
    Cancer: AUA Guideline. H Ballentine Carter, et al. PDF

    12 [NCCN-2A]
    NCCN 2015. Repeat test intervals for 45-75 yo (w NL DRE, if done): If PSA <1 ng/mL q2-4yrs; if ≥1 ng/mL, q1-2yrs. Prostate
    Cancer Early Detection, Version 2.2015. BRCA2 mutations assoc. w/ 2- to 6-fold increased prostate CA risk (less consistent for
    BRCA1). Online Accessed 12/8/15.

    13 ASCO 2012. Screening for Prostate Cancer With Prostate-Specific Antigen Testing: American Society of Clinical Oncology
    Provisional Clinical Opinion. PDF

    14 [AAFP-D]
    AAFP 2012. Clinical Preventive Service Recommendation, Prostate Cancer. Online Accessed 12/8/15.

    15 [USPSTF-D]
    USPSTF 2012 (update in progress). Convincing evidence that PSA-based screening detects many prostate CA cases, a
    substantial % w/ asymptomatic CA detected by PSA have a tumor that won’t progress—or will progress so slowly that it would’ve
    remained asymptomatic for a lifetime. Reduction in prostate CA mortality 10-14 yrs after PSA-based screening is very small, even
    for men in optimal age range of 55-69 yo. Prostate Cancer: Screening. PDF

    16 ACP 2015. Screening for Cancer: Advice for High-Value Care From the American College of Physicians. Timothy Wilt, et al. Ann
    Intern Med. 2015;162(10):718-725. PDF

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