Although new screening methods are being developed such as single- and adjusted-threshold testing and PSA velocity and doubling time , evidence is insufficient to support one method of PSA-based screening over another. Evidence is also insufficient that using a prebiopsy risk calculator, with or without measurement of free PSA levels, or using genetic or adjunctive imaging tests meaningfully changes the potential benefits and harms of screening.
This is an important area of current research that has the potential to decrease the harms of PSA-based screening for prostate cancer. The use of digital rectal examination as a screening modality is not recommended because there is a lack of evidence on the benefits; digital rectal examination was either eliminated from or not included in the major screening trials. These trials used varying screening intervals from 1-time screening to every 1 to 4 years and PSA thresholds 2. The PLCO trial may be viewed as a trial of organized vs opportunistic screening for prostate cancer because of the substantial screening rate in the control group and the high screening rate among men in both the control and intervention groups prior to study enrollment.
The trial found no difference between groups in death from prostate cancer after almost 15 years of follow-up absolute risk, 4. The results varied across the individual ERSPC sites, and prostate cancer mortality was significantly reduced only at the sites in the Netherlands and Sweden. However, point estimates were in favor of screening at all sites except Switzerland.
At the largest site Finland , there was no significant benefit observed for prostate cancer mortality rate ratio, 0. Four ERSPC trial sites reported data on the effect of PSA-based screening for prostate cancer on the development of metastatic cancer after 12 years of follow-up. This translates to an absolute reduction in the long-term risk of metastatic prostate cancer of 3.
After a median follow-up of 10 years, there was no significant difference in prostate cancer mortality between the invited group and the control group absolute risk, 0. Based on clinical stage, tumor grade, and PSA level, prostate cancer is classified as low, medium, or high risk for clinical progression and prostate cancer death. Although treatment is thought to be most immediately beneficial for men with high- and medium-risk prostate cancer, the vast majority of cases of screen-detected cancer are low risk.
Among 5 ERSPC sites that reported the false-positive rate, approximately 1 in 6 men screened at least once had 1 or more false-positive results, and of the positive results in the first round of screening, two-thirds were false positives. In Sweden, where a low PSA threshold 3.
The 3 large RCTs on screening predominantly included men aged 55 to 69 years. There is inadequate evidence on starting screening at a younger age in the average-risk population or to obtain a baseline PSA level. Evidence in men 70 years and older does not support routine screening because of the lack of trial evidence of benefit, the low likelihood of benefit given the time to realize benefit, and the increased risk of harms from false-positive results, biopsies, overdiagnosis, and treatment.
Although the evidence does not support routine screening in all men older than 70 years, the USPSTF recognizes the common use of PSA-based screening in practice today and understands that some older men will continue to request screening and some clinicians will continue to offer it. Men older than 70 years who request screening should be aware of the reduced likelihood of benefit from screening and the increased risk of false-positive test results and complications of diagnosis and treatment.
Clinically available RNA profiling tests of prostate tumors: utility and comparison. Harry Potter. The trial was rated as fair quality by the USPSTF review because of several important methodologic issues, including observed differences in how men in the screening and control groups were treated for prostate cancer. Advance Directives. April 12,
The USPSTF considered whether there are screening and follow-up approaches that increase the potential for benefit while reducing the potential for harms. Variation across sites in randomized trials of screening suggests there may be greater mortality benefit from screening every other year compared with longer intervals and from using lower PSA thresholds for diagnostic biopsy.
Although these approaches may have increased the potential benefit reported in studies, they also resulted in substantially more harms—more false-positive results, more prostate biopsies, and more cases of overdiagnosis. No ERSPC trial site offered screening more often than every 2 years, and many sites screened every 4 years. The potential benefit of screening for prostate cancer is because of treatment. Thus, it is important for men to consider both the potential benefits and harms of treatment including active surveillance as they consider whether to be screened.
Men not able or willing to tolerate treatment should not be screened for prostate cancer. Because most cases of prostate cancer advance very slowly, if at all, the year survival rate for screen-detected, localized prostate cancer is very high. Multiple treatment options exist for prostate cancer, and new ones are being developed.
In current practice, the 3 most common treatment options for men with screen-detected, localized prostate cancer are surgical removal of the prostate gland radical prostatectomy , radiation therapy external-beam radiation therapy, proton beam therapy, or brachytherapy , and active surveillance. The USPSTF considered available evidence on treatment when evaluating the effectiveness of screening and found that current evidence suggests that treatment of early-stage, screen-detected prostate cancer with radical prostatectomy or radiation therapy likely reduces risk of clinical progression and metastatic disease and may reduce prostate cancer mortality.
More details about the effectiveness and adverse effects of active treatment are provided in the Discussion section.
Active surveillance is a treatment approach that seeks to limit the harms of treatment by allowing men with apparent low-risk prostate cancer to forego surgery or radiation in favor of ongoing monitoring of their cancer. Although protocols vary, active surveillance usually includes regular, repeated PSA testing and often repeated digital rectal examination and prostate biopsy, with potential for exposure to repeated harms from biopsies.
Men whose cancer is found to be changing are offered definitive treatment with surgery or radiation therapy. Other treatment monitoring strategies for men with low-risk cancer exist for example, watchful waiting and also vary in protocol. Active surveillance has become a more common treatment choice in the United States over the past several years. In a study assessing community-based urology practice in the United States between and , about half of men with low-risk prostate cancer were treated with radical prostatectomy.
Active treatment of prostate cancer can result in major adverse effects. About 3 in men die during or soon after radical prostatectomy, and about 50 in men have serious surgical complications requiring intervention. About 1 in 5 men who undergo radical prostatectomy develop long-term urinary incontinence requiring regular use of pads, and about 2 in 3 men experience long-term erectile dysfunction.
More than half of men who receive radiation therapy experience long-term erectile dysfunction, and up to 1 in 6 men experience long-term bothersome bowel symptoms, including bowel urgency and fecal incontinence. In the United States, African American men are more likely to develop prostate cancer than white men African American men are also more than twice as likely as white men to die of prostate cancer These differences in death from prostate cancer may also reflect that African American men have lower rates of receiving high-quality care. The low proportion of persons of African descent in European countries during the study period makes it likely that these groups were not well represented.
An analysis from the PLCO trial found that African American men were significantly more likely to have major infections after prostate biopsy than white men odds ratio [OR], 7. Although it is possible that screening may offer greater benefits for African American men compared with the general population, currently no direct evidence demonstrates whether this is true.
Screening, and subsequent diagnosis and treatment, has the potential to increase exposure to potential harms. Decision analysis models suggest that given the higher rates of aggressive prostate cancer in African American men, PSA-based screening may provide greater benefit to African American men than the general population. These models also suggest a potential mortality benefit for African American men when beginning screening before age 55 years. The USPSTF believes that a reasonable approach for clinicians is to inform African American men about their increased risk of developing and dying of prostate cancer as well as the potential benefits and harms of screening so they can make an informed, personal decision about whether to be screened.
Although the USPSTF found inadequate evidence about how benefits may differ for African American men, it recognizes the epidemiologic data showing that African American men may develop prostate cancer at younger ages than average-risk men and understands that some African American men and their clinicians will continue to screen at younger ages. It is important to consider both the potential additional benefits and harms to fully understand the value of screening. Studies are needed to confirm that African American men who undergo screening receive similar or greater reductions in prostate cancer mortality compared with men in the general population, as well as to explore the optimal screening frequency and whether beginning screening before age 55 years provides additional benefits in African American men.
Studies are also needed to better understand strategies to mitigate harms and maximize benefits of screening, diagnostic follow-up, and treatment including active surveillance in African American men. It is also important that research and quality improvement activities continue to work to eliminate disparities in access to high-quality care for men with prostate cancer. The introduction of PSA-based screening for prostate cancer has substantially altered the epidemiologic data for prostate cancer, greatly increasing the number of men with a diagnosis of prostate cancer and thus also the number of men with a father, brother, or son with a history of prostate cancer.
It is generally accepted that men with a family history of prostate cancer are more likely to develop prostate cancer. No studies have assessed the risk of harms related to screening for, diagnosis of, or treatment of prostate cancer based on family history of prostate cancer. Based on the available evidence, the USPSTF is not able to make a separate, specific recommendation on PSA-based screening for prostate cancer in men with a family history of prostate cancer. Although it is possible that screening may offer additional potential benefits for these men compared with the general population, screening also has the potential to increase exposure to potential harms, especially among men with relatives whose cancer was overdiagnosed.
Men who have a first-degree relative who had advanced prostate cancer at diagnosis, developed metastatic prostate cancer, or died of prostate cancer are probably the most likely to benefit from screening. The USPSTF believes that a reasonable approach for clinicians is to inform men with a family history of prostate cancer, particularly those with multiple first-degree relatives with prostate cancer, about their increased risk of developing cancer as well as the potential earlier age at disease onset.
This discussion should include the potential benefits and harms of screening for prostate cancer so these men have the opportunity to make an informed, personal decision about whether to be screened. Although the USPSTF found inadequate evidence about how benefits may differ for men with a family history of prostate cancer, it recognizes the epidemiologic data showing that these men are at a greater than average risk and understands that some men and their clinicians will continue to screen at younger ages in men with a family history.
The USPSTF does not recommend screening for prostate cancer in men, including men with a family history of prostate cancer, older than 70 years. Epidemiologic studies examining outcomes in men with relatives who died of prostate cancer vs men with relatives diagnosed with prostate cancer who died of other causes may help provide better guidance. Studies are needed that explore the optimal screening frequency and whether beginning screening before age 55 years provides additional benefits for men with a family history of prostate cancer. Additional research is also needed to help identify men with an inheritable form of prostate cancer and to understand how the potential benefits and harms of screening, including screening intervals and starting ages, may differ in these men compared with the general population.
There are many areas in need of research to improve screening for and treatment of prostate cancer, including. To update its recommendation, the USPSTF commissioned a systematic review of the evidence regarding the benefits and harms of PSA-based screening for prostate cancer and subsequent treatment of screen-detected prostate cancer.
To understand the effectiveness of treatment of screen-detected, early-stage prostate cancer, the USPSTF also examined the results of 3 randomized trials and 9 cohort studies. The absolute reduction in long-term risk of metastatic prostate cancer associated with screening was 3. The results of the overall ERSPC trial provide some of the most important evidence about the potential benefits of PSA-based screening for prostate cancer.
The trial was rated as fair quality by the USPSTF review because of several important methodologic issues, including observed differences in how men in the screening and control groups were treated for prostate cancer. Among men diagnosed with nonmetastatic prostate cancer, a greater proportion of men in the screening group underwent radical prostatectomy The cause for these differences is not known. In the prostate component of the PLCO trial, more than 76, men aged 55 to 74 years were randomized to either annual PSA-based screening for 6 years or usual care.
Approximately one-third of men in both groups had either a PSA test or digital rectal examination within the 3 years prior to enrollment.
Prostate Cancer Screening: Second Edition (Current Clinical Urology): Medicine & Health Science Books @ giotartsiwell.tk Editorial Reviews. Review. From the reviews of the second edition: "This compilation of 27 chapters written by well known urology experts covers a wide range of.
Despite the common use of PSA testing in the control group, after 13 years more cases of prostate cancer were diagnosed in the screening group than in the control group At a median follow-up of The CAP trial was a cluster randomized trial in the United Kingdom among , men aged 50 to 69 years invited for a single PSA-based screening for prostate cancer. Men with localized prostate cancer were offered enrollment into the Prostate Testing for Cancer and Treatment ProtecT trial, in which the primary outcome was prostate cancer mortality.