What are the recommendations for prostate cancer screening?

From the Guidelines

Prostate cancer screening is recommended for men aged 55 to 69 years through shared decision-making with their healthcare provider, as stated in the most recent and highest quality study 1. The primary screening test is the prostate-specific antigen (PSA) blood test, typically performed every 1-2 years. Men with higher risk factors, including African American race or family history of prostate cancer, should consider beginning screening earlier, around age 40-45, as suggested by the American Cancer Society 1. The digital rectal examination (DRE) may be performed alongside PSA testing but is not recommended as a standalone screening method. Some key points to consider when making a decision about prostate cancer screening include:

• The benefit of screening is detecting cancer early when treatment is most effective, potentially reducing mortality, as seen in the European Randomized Study of Screening for Prostate Cancer (ERSPC) 1.
• Screening carries risks including false positives leading to unnecessary biopsies, overdiagnosis of slow-growing cancers that may never cause harm, and potential complications from subsequent treatments, as highlighted by the US Preventive Services Task Force (USPSTF) 1.
• The decision to screen should be individualized based on personal values, risk factors, and health status rather than applied universally to all men, as recommended by the American College of Physicians (ACP) 1. Some important considerations for screening include:
• Men under 40, over 70, or with less than 10-15 years life expectancy should not be screened, as the harms of screening outweigh the benefits in these populations, according to the ACP 1.
• The PSA test is not "just a blood test," but rather a test that can open the door to more testing and treatment that a man may not actually want and that may actually harm him, as noted by the ACP 1.
• Clinicians should help men understand the potential benefits and harms of screening, and make informed decisions based on their individual circumstances, as recommended by the ACS 1.

From the FDA Drug Label

In clinical studies, finasteride tablets reduced serum PSA concentration by approximately 50% within six months of treatment. For interpretation of serial PSAs in men taking finasteride tablets, a new PSA baseline should be established at least six months after starting treatment and PSA monitored periodically thereafter Any confirmed increase from the lowest PSA value while on finasteride tablets may signal the presence of prostate cancer and should be evaluated, even if PSA levels are still within the normal range for men not taking a 5α-reductase inhibitor.

The FDA drug label recommends monitoring PSA levels in men taking finasteride tablets, with a new baseline established at least six months after starting treatment.

• Key points to consider when interpreting PSA results in men taking finasteride include:
  • PSA levels may be reduced by approximately 50% within six months of treatment
  • Any confirmed increase from the lowest PSA value while on finasteride tablets may signal the presence of prostate cancer
  • PSA values should be doubled for comparison with normal ranges in untreated men to preserve the utility of PSA to detect prostate cancer in men treated with finasteride tablets 2 2

From the Research

Prostate Cancer Screening Recommendations

• The US Preventive Services Task Force (USPSTF) recommends that men aged 55 to 69 years discuss the potential benefits and harms of prostate-specific antigen (PSA)-based screening for prostate cancer with their clinician 3.
• The USPSTF concludes that the net benefit of PSA-based screening for prostate cancer in men aged 55 to 69 years is small, and the decision to undergo screening should be individualized 3.
• For men aged 70 years and older, the USPSTF recommends against PSA-based screening for prostate cancer, as the potential benefits do not outweigh the expected harms 3.
• The American Urological Association (AUA) also recommends shared decision-making for men aged 55 to 69 years considering screening 4.
• Digital rectal examination (DRE) alone is not recommended for prostate cancer screening, but may be used in combination with PSA testing 4, 5, 6.
• Novel formulas and algorithms, such as the Prostate Health Index (phi) and the 4Kscore, may improve the predictive value of PSA testing for detecting prostate cancer 4.
• Risk assessment with magnetic resonance imaging (MRI) and targeted biopsy may also improve detection rates and reduce the need for traditional biopsies 4.

Screening Methods

• PSA testing is the most common screening tool for prostate cancer, but may have limitations, including false-positive results and overdiagnosis 3, 4, 5, 6.
• DRE may be used to detect prostate cancer, particularly in combination with PSA testing, but has lower sensitivity and specificity than PSA testing 5, 6.
• Transrectal ultrasonography (TRUS) may be used to guide biopsies, but is not recommended as a primary screening tool 5, 6.
• Finasteride may improve the sensitivity of DRE for detecting prostate cancer, particularly for higher-grade tumors 7.

Special Considerations

• African American men and men with a family history of prostate cancer are at increased risk of developing and dying from prostate cancer, and may benefit from earlier or more frequent screening 3, 4.
• Men with comorbid medical conditions or other health needs should discuss the potential benefits and harms of screening with their clinician 3.
• Lifestyle modifications, such as diet and exercise, may help minimize the risk of prostate cancer, but the evidence is inconclusive 4.