From the Guidelines
Prostate cancer screening is recommended for men aged 55 to 69 years after discussing the potential benefits and harms with their healthcare provider, as stated in the most recent guideline from the American Cancer Society in 2018 1.
Key Recommendations
- The primary screening test is the prostate-specific antigen (PSA) blood test, typically performed annually or every 2-4 years depending on previous results and risk factors.
- Men with a family history of prostate cancer or African American men may benefit from starting screening earlier, around age 40-45.
- Screening is generally not recommended for men under 40 or over 70, or those with less than 10-15 years life expectancy.
Rationale
The decision to screen should be individualized based on personal values, risk factors, and overall health status, as the PSA test measures a protein produced by the prostate gland, with levels above 4.0 ng/mL often triggering further evaluation.
Potential Harms
PSA screening involves a trade-off between detecting potentially harmful cancers early and the risks of overdiagnosis and overtreatment of slow-growing cancers that may never cause symptoms, including false positives leading to unnecessary biopsies, complications from biopsies, and psychological distress, as noted in the 2012 USPSTF recommendation statement 1.
Guideline Comparison
The American College of Physicians (ACP) also recommends that clinicians inform men between the age of 50 and 69 years about the limited potential benefits and substantial harms of screening for prostate cancer, and base the decision to screen on the risk for prostate cancer, a discussion of the benefits and harms of screening, the patient's general health and life expectancy, and patient preferences, as stated in their 2013 guidance statement 1.
Risk Stratification
An alternative approach to risk stratification that integrates age, age-specific PSA levels, and risk factors into prostate cancer screening recommendations and consideration of referral for biopsy has been proposed by investigators at the Memorial Sloan Kettering Cancer Center (MSKCC), which starts screening men at age 45 years, with the interval for further screening based on initial and subsequent PSA levels, as described in the 2018 American Cancer Society guideline 1.
From the Research
Prostate Cancer Screening Recommendations
- The European Randomised Study of Screening for Prostate Cancer (ERSPC) reported a significant reduction in prostate cancer-specific mortality (RR 0.84,95% CI 0.73 to 0.95) in a pre-specified subgroup of men aged 55 to 69 years 2.
- A 21-year follow-up study of the Rotterdam section of the ERSPC found that prostate-specific antigen (PSA)-based screening reduced prostate cancer-specific mortality (RR 0.73,95% CI 0.61-0.88) and metastatic disease (RR 0.67,95% CI 0.58-0.78) in men aged 55-69 years 3.
- The US Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial found no significant benefit of screening on prostate cancer-specific mortality (RR 1.15,95% CI 0.86 to 1.54) 2.
- A study published in 2005 noted that PSA screening had not been shown to lower disease-specific mortality rates, but recommended measurement of PSA from age 45 onwards in patients who had been comprehensively informed about the further proceedings in the event of a positive result 4.
- Active surveillance is considered a viable option for men with low-risk prostate cancer, with studies demonstrating its efficacy and safety 5, 6.
Key Considerations
- The benefits and harms of prostate cancer screening should be carefully considered, including the risk of overdiagnosis and overtreatment 2, 3.
- Men should be informed of the potential risks and benefits of screening, including the risk of false-positive results, bleeding, bruising, and short-term anxiety 2.
- The age at which screening is started and the frequency of screening should be carefully considered, with some studies suggesting that screening may not be beneficial for men with a life expectancy of less than 10-15 years 2, 3.
- Active surveillance may be a suitable option for men with low-risk prostate cancer, but the selection criteria and follow-up method should be carefully determined and established 6.