Prostate Cancer Screening Guideline Updated by ACS

From MedscapeCME Clinical Briefs

News Author: Nick Mulcahy
CME Author: Penny Murata, MD

03/09/2010

The most commonly diagnosed cancer in men in the United States and the second leading cause of cancer death in men is prostate cancer, as reported by Jemal and colleagues in the July-August 2009 issue of CA: A Cancer Journal for Clinicians.

However, the benefits and harms of early detection of prostate cancer are not clear. The European Randomized Study of Screening for Prostate Cancer, described by Schroder and colleagues in the March 26, 2009, issue of the New England Journal of Medicine, found that men randomly assigned to screening had a 20% reduction in prostate cancer-specific mortality rates. However, the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial in the United States, described by Andriole and colleagues in the March 26, 2009, issue of the New England Journal of Medicine, reported no reduction in mortality rates.

This ACS guideline for prostate cancer screening updates the previous 2001 guideline.

Study Highlights

The ACS Prostate Cancer Advisory Committee evaluated systematic reviews, and identified studies from 1950 to June 2009 by Medline search.
The guidelines were approved by the ACS Mission Outcomes Committee and the ACS Board of Directors.
The Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial and the European Randomized Study of Screening for Prostate Cancer prospective randomized studies of screening had different efficacy results.

Asymptomatic men with at least a 10-year life expectancy should be offered informed decision making about prostate cancer screening.
Information provided should cover uncertainties, risks, and benefits of screening.
Information source should be the healthcare provider or a reliable and culturally appropriate source.
Community-based screening programs are not recommended unless adequate informed decision making and appropriate follow-up care are available.
Patient decision aids improve patients' knowledge, but there is no evidence about

For men who cannot decide, the healthcare provider should consider the patients' general health preferences and values.
The age to begin screening is linked to risk:
At age 50 years for average-risk men
At age 45 years for higher-risk men (African American ethnicity or first-degree relative with prostate cancer before age 65 years)
At age 40 years for appreciably higher-risk men (multiple family members diagnosed with prostate cancer before age 65 years)
Prostate cancer screening is not recommended in men with a life expectancy of less than 10 years based on age and health status because of low benefit relative to the

The recommendations for follow-up depend on PSA level.
If PSA level is less than 2.5 ng/mL, screening is recommended every 2 years; for levels of 2.5 ng/mL or higher, screening is recommended every year.
If PSA level is between 2.5 to 4.0 ng/mL, individualized decision making is recommended:
Biopsy is recommended for high-risk patients (African American, family history of prostate cancer, increasing age, and an abnormal DRE result).
Previous negative biopsy result confers lower risk.
The traditional PSA threshold level of 4.0 ng/mL is considered reasonable for biopsy, although a true cutoff level has not been determined.

Screening harms from phlebotomy and DRE are not significant.
Weak evidence exists of low anxiety linked with screening process and slightly greater anxiety linked with awaiting biopsy.
Stronger evidence exists that false-positive PSA results are linked with cancer worry and more subsequent tests and visits.
Estimated overdiagnosis rates range from 23% to 42% of screen-detected cancers.
Adverse effects of radical prostatectomy include bleeding, 30-day complication rates of approximately 22%, death in 0.1% to 0.2%, anastomotic stricture of the bladder and urethra in 5% to 14%, urinary incontinence in 12% to 16%, and sexual dysfunction in 19% to 27%.
Adverse effects of radiation therapy include acute toxicities in 50% and late toxicities (erectile dysfunction in up to 50%).
Adverse effects of hormonal therapy are reported briefly because hormonal treatment is chiefly for advanced disease.
The harms of watchful waiting or active surveillance are obstructive symptoms and subsequent biopsy, but the quality-of-life effect is not known.
PSA velocity should not be routinely included in screening.
DRE has an unclear role in screening but can be useful if PSA level is between 2.5 and 4.0 ng/mL.

Clinical Implications

Prostate cancer screening by PSA with or without DRE is recommended after informed decision making beginning at age 50 years for asymptomatic men at average risk with at least a 10-year life expectancy, beginning at age 45 years in African American men and in men with a first-degree relative diagnosed with prostate cancer younger than 65 years, and beginning at age 40 years in men with multiple first-degree relatives diagnosed with prostate cancer younger than 65 years.

In men who undergo prostate cancer screening with PSA levels less than 2.5 ng/mL, screening is recommended every 2 years. If PSA level is between 2.5 and 4.0 ng/mL, annual screening is recommended with possible biopsy in African American men and in men with a family history of prostate cancer, increasing age, or abnormal DRE result. If PSA level is 4.0 ng/mL or more, referral for evaluation or biopsy is recommended.