From the Guidelines
Prostate-specific antigen (PSA) screening for prostate cancer should be individualized for men aged 55-69, with a discussion of potential benefits and harms, while men aged 70 and older should not be screened as harms likely outweigh benefits. The U.S. Preventive Services Task Force recommends this approach, citing potential benefits including reduced prostate cancer mortality (approximately 1.3 fewer deaths per 1,000 men screened over 13 years) 1. However, screening carries significant harms including false positives (leading to unnecessary biopsies), overdiagnosis of indolent cancers, and treatment complications like incontinence and erectile dysfunction.
Some key points to consider in the decision-making process include:
- The potential benefits of screening, including reduced mortality from prostate cancer
- The harms associated with screening, including false positives, overdiagnosis, and treatment complications
- The importance of shared decision-making between patients and healthcare providers
- The consideration of personal risk factors, such as family history and African American race
- The variation in screening frequency, with decreasing frequency as men age
The evidence from recent studies, such as the 2019 review of cancer screening in the United States 1, supports this individualized approach to PSA screening. The American College of Physicians also recommends a similar approach, emphasizing the importance of shared decision-making and consideration of patient preferences and values 1.
In terms of specific screening protocols, the PSA test is the most commonly used screening tool, with values above 4.0 ng/mL often triggering further evaluation. However, the threshold for further evaluation may vary depending on age and risk factors. Digital rectal examination (DRE) may also be used in combination with PSA screening, although the evidence for its benefit is limited.
Ultimately, the decision to undergo PSA screening should be made on an individual basis, taking into account the potential benefits and harms, as well as patient preferences and values. As stated by the USPSTF, "the decision to undergo periodic PSA-based screening should be an individual one and should include discussion of the potential benefits and harms of screening with their clinician" 1.
From the Research
Overview of Prostate-Specific Antigen (PSA) Screening
- PSA screening is a controversial topic in the medical field, with some studies suggesting a reduction in cancer-specific mortality, while others highlight the potential harms of overdiagnosis and overtreatment 2, 3, 4.
- The US Preventive Services Task Force (USPSTF) has revised its recommendation to offer PSA testing to men aged 55-69 years with shared decision-making, taking into account the potential benefits and harms of screening 2.
Benefits of PSA Screening
- Level 1 evidence from randomized controlled trials suggests a reduction in cancer-specific mortality from PSA screening, with one study showing a 64% reduction in prostate cancer deaths for men aged 55-75 years 5.
- PSA screening can lead to earlier diagnosis and treatment of prostate cancer, potentially improving outcomes for patients 3, 6.
Harms of PSA Screening
- Overdiagnosis and overtreatment are significant concerns with PSA screening, with one study estimating that 37 additional men need to be diagnosed with prostate cancer to prevent one death from the disease 3.
- False-positive results and complications from biopsy and treatment are also potential harms of PSA screening 3, 4.
Guidelines and Recommendations
- Different medical organizations have varying recommendations for PSA screening, with some suggesting that all men should be informed of the potential benefits and drawbacks of screening and make an informed decision 4, 6.
- The American Cancer Society and the American Urological Association recommend shared decision-making for PSA screening, taking into account individual patient preferences and risk factors 2, 4.