What are the guidelines for prostate cancer screening?

From the Guidelines

Prostate cancer screening is recommended for men aged 55-69 years through a shared decision-making process with their healthcare provider. 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 1. Men at higher risk, including African American men and those with a family history of prostate cancer, should consider beginning screening at age 40-45. The digital rectal examination (DRE) may also be performed as part of the screening process.

Key Considerations

• Screening is generally not recommended for men under 40, over 70, or with less than 10-15 years life expectancy 1.
• The PSA threshold that triggers further investigation is typically 4 ng/mL, though this may vary based on age and other factors.
• If elevated PSA is found, additional tests like free PSA percentage, prostate MRI, or prostate biopsy may be recommended.
• Prostate cancer screening aims to detect cancer early when treatment is most effective, but it carries risks of false positives, overdiagnosis, and potential complications from follow-up procedures, which is why the decision to screen should be individualized based on personal values and preferences 1.

Benefits and Harms

• The benefits of screening include a reduction in prostate cancer mortality, with a relative risk reduction of 21% at a median follow-up of 11 years 1.
• The harms of screening include false positives, overdiagnosis, and potential complications from follow-up procedures, such as infections and urine retention resulting from biopsies 1.

Shared Decision-Making

• Clinicians should engage in shared decision-making with patients to discuss the benefits and harms of screening, and to determine whether screening is appropriate based on individual risk factors and preferences 1.

From the Research

Prostate Cancer Screening

• The US Preventive Services Task Force (USPSTF) recommends that men aged 55 to 69 years discuss the benefits and harms of prostate-specific antigen (PSA)-based screening with their clinician, as the net benefit is small for some men 2.
• For men aged 55 to 69 years, the decision to undergo periodic PSA-based screening should be individualized, considering factors such as family history, race/ethnicity, and comorbid medical conditions 2.
• The USPSTF recommends against PSA-based screening for prostate cancer in men 70 years and older, as the potential benefits do not outweigh the expected harms 2.

Benefits and Harms of Screening

• PSA-based screening programs in men aged 55 to 69 years may prevent approximately 1.3 deaths from prostate cancer over approximately 13 years per 1000 men screened 2.
• However, screening also has potential harms, including frequent false-positive results, psychological harms, and treatment complications such as erectile dysfunction and urinary incontinence 2.
• The use of dutasteride, a 5α-reductase inhibitor, has been shown to reduce the relative risk of prostate cancer diagnosis by 40% compared to tamsulosin monotherapy 3.

Risk Factors and Detection

• Factors associated with an increased risk of prostate cancer include high PSA value, rising PSA, family history of prostate cancer, abnormal digital rectal examination (DRE) result, African American race, and older age 4.
• A prior negative biopsy is associated with decreased risk of prostate cancer and high-grade prostate cancer 4.
• A rising PSA in men using dutasteride should be an indication for prostate biopsies, but a substantial proportion of Gleason 7-10 cases may be missed if a rising PSA is used as the only biopsy indication 5.

Subgroup Analysis

• A retrospective cohort study based on the European Randomised Study of Screening for Prostate Cancer (ERSPC) found that prostate cancer mortality reduction by screening is largely attributable to stage shift, and the screening effect appears to depend on screening duration and frequency 6.
• The study was unable to unequivocally identify the optimal age group for screening, as mortality reduction differed among centers and age groups 6.