From APTR & ACPM
Screening for Prostate Cancer in U.S. Men: ACPM Position Statement on Preventive Practice

https://doi.org/10.1016/j.amepre.2007.10.003Get rights and content

Introduction

Prostate cancer is the leading cancer in U.S. men, and the third leading cause of cancer deaths. Principal screening tests for detection of asymptomatic prostate cancer include digital rectal examination (DRE) and measurement of the serum tumor marker, prostate-specific antigen (PSA). There are risks and benefits associated with prostate cancer screening. Randomized controlled trials of screening by DRE and PSA are limited to two previously published studies. Two other large-scale randomized controlled trials are currently in progress.

Methods

This study reviewed the efficacy of DRE and PSA for prostate cancer screening found in the medical literature prior to July 2007.

Results

Applications of PSA screening tests used in clinical practice include (1) a PSA cutoff of 4 ng/ml, (2) age-specific PSA, (3) PSA velocity, (4) PSA density, and (5) percent free PSA. Prostate cancer screening can detect early disease and offers the potential to decrease morbidity and mortality. Prostate cancer screening benefits, however, remain unproven, pending results of ongoing trials. There is currently no convincing evidence that early screening, detection, and treatment improves mortality. Limitations of prostate cancer screening include potential adverse health effects associated with false-positive and negative results, and treatment side effects.

Conclusions

The American College of Preventive Medicine concludes that there is insufficient evidence to recommend routine population screening with DRE or PSA. Clinicians caring for men, especially African-American men and those with positive family histories, should provide information about potential benefits and risks of prostate cancer screening, and the limitations of current evidence for screening, in order to maximize informed decision making.

Introduction

Prostate cancer is currently the leading type of cancer for men in the United States, representing one third of incident cancer cases. It is the second leading cause of cancer deaths in American men (after lung cancer). In 2007, an estimated 218,890 new cases were diagnosed and 27,050 men died of prostate cancer.1 It has surpassed colorectal cancer deaths, which was ranked second, in 2006. One in every six U.S. men will develop invasive prostate cancer before his death.1 Age-adjusted incidence of prostate cancer has been increasing over the last 50 years and peaked in the early 1990s, associated mostly with increased early detection due to the introduction of prostate-specific antigen (PSA) in the late 1980s (Figure 1, Figure 2).2 There was also a similar trend in prostate cancer–related mortality.3 Fortunately, the past decade has seen declines in both incident and mortality rates.

From 1973 to 2003, the disease-specific 5-year survival rate for localized or regional prostate cancer was 96%, and was 53% for distant metastases.4 Genetic, environmental, and social risk factors have been identified for prostate carcinoma, including familial, dietary, hormonal, and possibly environmental carcinogen influences.5 Prostate cancer incidence increases with age, and men with a family history of prostate cancer and African-American men are at higher risk of both developing and dying from prostate cancer. The aim of this statement is to review the efficacy of digital rectal exam (DRE) and PSA for prostate cancer screening found in the medical literature prior to July 2007.

Section snippets

Evidence of Effectiveness of Current Preventive Measures

The principal screening tests for the detection of asymptomatic prostate cancer are the DRE and serum PSA levels. Transrectal ultrasound (TRUS) is no longer considered a first-line screening test for prostate cancer but does play a role in the investigation of patients with abnormal DRE or PSA when guided biopsies are required. With regards to prostate cancer detection, it has been reported previously that DRE has a sensitivity of 55%–68% in asymptomatic men,6, 7 but values as low as 18%–22%

Rationale Statement

Prostate cancer is a significant cause of cancer and cancer-related mortality among U.S. men. Screening can detect prostate cancer early, and even though early detection through screening may increase morbidity as a result of treatment, screening has the potential to decrease prostate cancer–associated mortality. However, the benefits of screening are unproven and may not be realized because of the characteristics of this disease (e.g., prevalence of latent clinically insignificant prostate

Recommendations of Other Groups

The American Urological Association recommends that PSA screening be offered to men beginning at 50 years of age and who have an estimated life expectancy of greater than 10 years.48 Men with first-degree relatives who have prostate cancer and African-American men may benefit from screening at an earlier age. The American Cancer Society recommends that both DRE and PSA screening be offered annually to men aged 50 years and over and have a life expectancy of greater than 10 years.49 Both the

Recommendation of the American College of Preventive Medicine

The American College of Preventive Medicine (ACPM) concludes that there is currently insufficient evidence to recommend routine population screening with DRE or PSA, concurring with the USPSTF recommendation. The College is in agreement with the ACP that men should be given information about the potential benefits and harms of screening and limits of current evidence in order to make an informed decision about screening. Discussion about screening should occur annually, during the routine

Additional Resources

The ACPM recognizes the challenges of presenting complex information on prostate cancer screening in the course of a brief office visit. Therefore, in addition to the key points listed in Table 1, additional tools can be utilized to assist the clinician to communicate the benefits and harms of prostate cancer screening with the patient. Resources from easily accessible national and reputable medical websites can supplement the face-to-face counseling in the office to aid the patient in the

References (60)

  • R. Lee et al.

    A meta-analysis of the performance characteristics of the free prostate-specific antigen test

    Urology

    (2006)
  • C.G. Roehrborn et al.

    Serum prostate-specific antigen as a predictor of prostate volume in men with benign prostatic hyperplasia

    Urology

    (1999)
  • M. McNaughton-Collins et al.

    Psychological effects of a suspicious prostate cancer screening test followed by a benign biopsy result

    Am J Med

    (2004)
  • A. Jemal et al.

    Cancer statistics, 2007

    CA Cancer J Clin

    (2007)
  • Surveillance, Epidemiology, and End Results (SEER) Program SEER*Stat Database: Incidence—SEER 9 Regs Limited-Use, Nov...
  • Surveillance, Epidemiology, and End Results (SEER) Program SEER*Stat Database: Mortality—All COD, Public-Use With...
  • NCI. SEER*Stat Database: Incidence—SEER 17 Regs Public-Use, Nov 2005 Sub (1973–2003 varying) April 2006 (based on the...
  • G.P. Haas et al.

    Epidemiology of prostate cancer

    CA Cancer J Clin

    (1997)
  • W.J. Catalona et al.

    Measurement of prostate-specific antigen in serum as a screening test for prostate cancer

    N Engl J Med

    (1991)
  • W.L. Lubke et al.

    Analysis of the first-year cost of a prostate cancer screening and treatment program in the United States

    J Natl Cancer Inst

    (1994)
  • P. Vihko et al.

    Screening for carcinoma of the prostateRectal examination, and enzymatic and radioimmunologic measurements of serum acid phosphatase compared

    Cancer

    (1985)
  • F.H. Schroder et al.

    The story of the European Randomized Study of Screening for Prostate Cancer

    BJU Int

    (2003)
  • K.E. Richert-Boe et al.

    Screening digital rectal examination and prostate cancer mortality: a case-control study

    J Med Screen

    (1998)
  • F. Labrie et al.

    Screening decreases prostate cancer mortality: 11-year follow-up of the 1988 Quebec prospective randomized controlled trial

    Prostate

    (2004)
  • G. Sandblom et al.

    Clinical consequences of screening for prostate cancer: 15 years follow-up of a randomised controlled trial in Sweden

    Eur Urol

    (2004)
  • D. Ilic et al.

    Screening for prostate cancer

    Cochrane Database Syst Rev

    (2006)
  • G.L. Andriole et al.

    Prostate cancer screening in the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial: findings from the initial screening round of a randomized trial

    J Natl Cancer Inst

    (2005)
  • J. Presti et al.

    Performance of PSA levels between 4 and 10 ng/mL in the era of extended biopsy schemes

    Program and abstracts of the American Urological Association 2006 Annual Meeting

    (2006)
  • I.M. Thompson et al.

    Prevalence of prostate cancer among men with a prostate-specific antigen level < or =4.0 ng per milliliter

    N Engl J Med

    (2004)
  • M. Hakama et al.

    Validity of the prostate specific antigen test for prostate cancer screening: followup study with a bank of 21,000 sera in Finland

    J Urol

    (2001)
  • Cited by (0)

    The members of ACPM’s Prevention Practice Committee are: Gershon H. Bergeisen, MD, MPH; Michael T. Compton, MD, MPH; V. James Guillory, DO, MPH, FACPM (Chair); Doug I. Hammer, MD, MPH, DrPH; Joylene John-Sowah, MD, MPH; Steven Jonas, MD, MPH (Consultant); Elizabeth Kann, MD, MPH; Ronit B. Katz, MD, FACPM; Robin McFee, DO, MPH, FACPM; Elaine S. Perry, MD, MS; Jennifer E. Rogers, MPH (Staff); and Michele A. Surricchio, MPH, CHES (Staff).

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