Prostate cancer screening
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According to the U.S. Preventive Services Task Force (USPSTF), there is insufficient evidence to recommend routine screening for prostate cancer and that the decision should be an individual choice after understanding that overdiagnosis and overtreatment can be significant side-effect in false positives. According to the American Cancer Society (ACS) guidelines, screening for prostate cancer by prostate specific antigen (PSA) and digital rectal exam (DRE) is recommended once among individuals age 50 years, age 45 years for African-American men and men with a family history of prostate cancer, and age 40 years for men with a very strong family history of prostate cancer. According to the American Urological Association (AUA) guidelines, screening for prostate cancer by PSA is recommended every 2 years among individuals age 55 to 69 years, or younger than 55 years for individuals with high risk.
Prostate cancer screening options include the digital rectal exam and the prostate specific antigen (PSA) blood test. Screening for prostate cancer is controversial because it is not clear if the benefits of screening outweigh the risks of follow-up diagnostic tests and cancer treatments.
Prostate-specific antigen (PSA)
- The PSA is a kallikrein. A four kallikrein panel includes total PSA, free PSA, intact PSA and human kallikrein-related peptidase-2 (hK2) and improves accuracy of predicting high-grade cancer (Gleason ⩾7) at biopsy.
- According to the American Cancer Society (ACS) guidelines, screening for prostate cancer by PSA and DRE is recommended once among individuals age 50 years, age 45 years for African-American men and men with a family history of prostate cancer, and age 40 years for men with a very strong family history of prostate cancer.They should be retested every year if the prostate specific antigen is 2.5ng/ml or more and once every 2 years if less than 2.5mg/ml.
- The 2007 National Comprehensive Cancer Network (NCCN) guideline recommends offering a baseline PSA test and DRE at ages 40 and 45, and annual PSA testing and DRE beginning at age 50 (with annual PSA testing and DRE beginning at age 40 for African-American men, men with a family history of prostate cancer, and men with a PSA ≥ 0.6 ng/mL at age 40 or PSA > 0.6 ng/mL at age 45) through age 80, along with information on the risks and benefits of screening.
- According to the American Urological Association (AUA) guidlines, screening for prostate cancer by PSA is recommended every 2 years among individuals age 55 to 69 years, or younger than 55 years for individuals with high risk.
Since there is no general agreement that the benefits of PSA screening outweigh the harms, the consensus is that clinicians use a process of shared decision-making that includes discussing with patients the risks of prostate cancer, the potential benefits and harms of screening, and involving the patients in the decision.
- Screening tests are able to detect prostate cancer at an early stage, but it is not clear whether this earlier detection and consequent earlier treatment leads to any change in the natural history and outcome of the disease. Observational evidence shows a trend toward lower mortality for prostate cancer in some countries, but the relationship between these trends and intensity of screening is not clear, and associations with screening patterns are inconsistent. The observed trends may be due to screening, or to other factors such as improved treatment. Results from two randomized trials show no effect on mortality through 7 years but are inconsistent beyond 7 to 10 years.
- Based on solid evidence, screening with PSA and/or DRE detects some prostate cancers that would never have caused important clinical problems. Thus, screening leads to some degree of overtreatment. Based on solid evidence, current prostate cancer treatments, including radical prostatectomy and radiation therapy, result in permanent side effects in many men.
Multiparametric magnetic resonance imaging (mpMRI)
- mpMRI may be more accurate and is being studied with a four kallikrein panel in a randomized controlled trial of screening.
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