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screening for prostate cancer

indications: 1) USPSTF advises discussions of potential benefits & harms with middle-aged men who are interested in screening [45] - previously no screening for healthy men [15,16,19] (USPSTF) - clinicians discuss the potential benefits & harms of prostate cancer screening with men aged 55-69 years [40] - decision should be individualized [40] (USPSTF) - avoid screening in patients who do not express a preference [1] 2) screening is associated with overdiagnosis and overtreatment [10] - for elderly men who need to be convinced to discontinue screening, use "your other medical issues should take priority" [51] - 1st-line serum PSA with 2nd-line multiparametric MRI is cost-effective [55] - MyProstateScore 2.0 (mpsa) stratifies risk for prostate cancer 3) small if any reduction in mortality [8] a) number needed to screen to prevent 1 death: - 293 [11], 1200-1400 (within 9 years) [13] b) relative risk of death within 13 years is 0.79 for men screened with serum PSA [31] - editorialist notes: overdiagnosis is common (40% of positive PSA screens) & that these results should not alter recommendations of USPSTF [31] c) no reduction in mortality [2,3,4,12,14] d) screening of men 55-69 years every 4 years might be cost-effective if low-risk cancer on biopsy is managed by active surveillance [42] e) offering screening with serum PSA does not reduce mortality [44] 4) American Society of Clinical Oncology recommends discussion of screening with patient if expected survival > 10 years, including harms of screening [20] - many cancer centers recommend universal screening with serum PSA [50] 5) American College of Physicians recommendations [23,33] a) inform men between ages 50-69 about limited potential benefits & substantial harms of prostate screening b) do not test men who do not express a clear preference for screening c) do not screen average-risk men under age 50 d) do not screen men > 69 years of age, or those with a life expectancy of < than 10-15 years e) evidence is mixed on whether digital rectal exam is beneficial alone or in combination with serum psa 6) American Urologic Association a) screen only in men age 50-69 based on shared decision- making & the patient's preferences (average risk) [26,54] - earier screening for high-risk patients b) serum PSA every 2-4 years for those who elect for screening [54] c) stop screening at age 60 years if serum PSA < 1 ug/l [39] d) always repeat an elevated serum PSA prior to further investigation [54] 7) American Cancer Society (2010) [30] a) annual serum PSA for men with serum PSA >= 2.5 ug/l b) serum PSA every 2 years for men with serum PSA < 2.5 ug/l c) stop screening at age 60 years if serum PSA < 1 ug/l [39] 8) Canadian Task Force recommends not screening men with serum PSA [32] 9) former recommendations a) no consensus, proceed with screening after discussion of benefits vs risks [1] b) American Cancer Society (acs) & american urologic association (aua) - all men over 50, high-risk men over 40 - annual digital rectal exam (DRE) - lack of evidence supporting DRE [43] - annual prostate-specific antigen (PSA)* c) National Cancer Institute (nci) & American College of Physicians: - insufficient evidence to justify routine screening d) US Preventive Services Task Force (USPSTF) - insufficient evidence to recommend for or against routine screening with psa or digital rectal exam e) Kaiser Permanente - annual serum PSA* after age 50 (age 40 if African-American or family history of prostate cancer) - 4 year interval for screening may be acceptable - if seum PSA is > 4 ug/l (> 6 ug/l if > 65 years of age), order free PSA - if %free psa is < 25%, then refer patient to urology for prostate biopsy - if patient is > 75 years, free PSA is not necessary - if patient is > 75 years & serum PSA is > 20 ug/l, refer to urology for hormone therapy 10) Prostate, Lung, Colorectal & Ovarian (PLCO) screening trial ongoing 11) lower rate of prostate cancer mortality in usa compared with uk (1975-2003) coincides with much higher rate of PSA screening in usa [6] a) no change in overall mortality with screening [17] b) after massaging data from both uk & u.s, 25-30% reduction in prostate cancer mortality over 11 years [41] c) number needed to screen to prevent one death from prostate cancer = 1055 [17] 12) absence of PSA screening for prostate cancer as recommended by USPSTF may triple risk for presentation with metastatic prostate cancer [21] 13) drop in PSA screening associated with increase in cases presenting with metastatic prostate cancer [47] Laboratory: - prostate-specific antigen in serum (serum PSA) - low serum PSA (< 1.0 ng/mL) at age 60 confers low probability of metastatic disease by age 85 [11] - another study offers different thresholds for different ages & makes screening recommendations based upon low normal serum PSA levels [24] - study suggests if serum PSA < 2 ug/L at age 60 years, no need for further screening [29] - continuing to screen men > 60 years of age with serum PSA > 2 ug/L may prevent prostate cancer-related death: number needed to screen = 23 to prevent 1 death - neither digital rectal examination or serum PSA < 4 ug/L rules out prostate cancer - repeat serum PSA prior to prostate biopsy [35] - urine 18-gene prostate cancer test may reduce need for MRI &/or biopsy maintaining high-sensitivity for high-grade prostate cancers [56] Radiology: - MRI-guided screening with biopsy only when MRI suggestive of prostate cancer [48,53] - serum PSA 3-10 ng/mL - strategy confers several advantages: - substantially lowers number of prostate biopies without signifcant compromise in detection of clinically significant prostate cancer [57] - intermediate risk prostate cancers missed by this approach can be detected by active surveillance [53] - reduces number of men who receive a diagnoses of clinically insignificant prostate cancer [48,57] Notes: - - screening continues unabated in elderly men despite USPSTF 2008 recommendation against screening [18,28,36] - for elderly men who need to be convinced to discontinue screening, use "your other medical issues should take priority" [51] - incidence of prostate cancer has declined along with rate of prostate cancer screening [34] since USPSTF recommendations of 2012 [19] - prostate cancer screening with serum PSA has declined in primary care offices, since USPSTF recommendations of 2012, but not in urology offices [37] - 79% of prostate cancers are detected by screening despite USPSTF recommenedation [52] - PSA testing has increased the number of men diagnosed with & treated for prostate cancer, but many of these men would never have experienced any symptoms from prostate cancer [46] - men who place more value on avoiding complications from prostate biopsy & prostate cancer treatment are likely to decline screening [46]

Related

digital rectal examination (DRE) prostate prostate biopsy prostate cancer prostate specific antigen (PSA) in serum

General

screening for cancer

References

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