What are the recommendations for prostate screening in men?

Prostate Cancer Screening Recommendations

For men aged 55-69 years, prostate cancer screening should be offered only after a thorough shared decision-making process that discusses both potential benefits and harms, as this is the only age group where benefits may outweigh harms. 1

Age-Based Screening Recommendations

• Men aged 55-69 years:

  • Offer PSA screening only after shared decision-making 1, 2
  • Potential benefit: May prevent approximately 1.3 deaths from prostate cancer per 1,000 men screened over 13 years 1, 2
  • Potential harms: Overdiagnosis, false positives, and treatment complications 1

• Men aged 70 years and older:

  • PSA screening is NOT recommended 1, 2
  • Harms outweigh benefits in this age group 3, 2

• Men younger than 55 years:

  • General population: Routine screening not recommended 1
  • Higher risk men (African American men or those with family history): Consider starting at age 45 1
  • Very high risk men (multiple family members diagnosed before age 65): Consider starting at age 40 1

Screening Frequency

PSA screening should be risk-stratified based on baseline PSA levels 1:

• PSA <1.0 ng/mL: Every 2-4 years
• PSA 1.0-2.5 ng/mL: Every 2 years
• PSA ≥2.5 ng/mL: Annually

Screening Method

• PSA blood test is the primary screening tool 1, 2
• Digital rectal examination (DRE) alone is not very sensitive but may be used in combination with PSA 1
• The conventional PSA screening cut-point is 4.0 μg/L 3

Shared Decision-Making Process

Before ordering a PSA test, clinicians should discuss:

1. Potential benefits:

   • Reduction in prostate cancer mortality by approximately 21% 1
   • Prevention of approximately 3 cases of metastatic prostate cancer per 1,000 men screened 2

2. Potential harms:

   • False-positive results requiring additional testing 3, 1
   • Overdiagnosis of clinically insignificant cancers 1, 2
   • Treatment complications including:
     • Urinary incontinence (affects about 1 in 5 men after radical prostatectomy) 1, 2
     • Erectile dysfunction (affects about 2 in 3 men) 1, 2
     • Bowel symptoms 1

Special Considerations

• Life expectancy: Screening should be limited to men with greater than 10 years life expectancy 3, 4
• Higher risk populations:
  • African American men: Higher incidence (173.0 cases per 100,000 vs 97.1 cases per 100,000 in White men) 5
  • Men with family history of prostate cancer 3, 1

Management After Positive Screening

If PSA is elevated:

1. Repeat the test to confirm elevation 6
2. If still elevated, consider:
   • Multiparametric MRI 6
   • Assessment of additional biomarkers 6
   • Referral to urology 6

For diagnosed prostate cancer:

• Low-risk disease: Active surveillance is increasingly the preferred standard of care 6
• Higher-risk disease: Consider radiation therapy or radical prostatectomy 5

Common Pitfalls to Avoid

1. Screening without shared decision-making: All guidelines emphasize the importance of discussing benefits and harms before testing 3, 1

2. Screening men with limited life expectancy: Men with less than 10 years life expectancy are unlikely to benefit from screening 3

3. Automatic annual screening: Evidence suggests that less frequent screening (every 2-4 years) may provide similar benefits with fewer harms 3, 1

4. Overtreatment of low-risk disease: Active surveillance is appropriate for many men with low-risk prostate cancer 6