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| __NOTOC__ | | __NOTOC__ |
| {{CMG}} | | |
| | {{CMG}} {{AE}} {{sali}} |
| {{Prostate cancer}} | | {{Prostate cancer}} |
| ==Overview== | | ==Overview== |
| According to the AUA guidline, 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.<ref name="pmid23924423">{{cite journal| author=Carter HB| title=American Urological Association (AUA) guideline on prostate cancer detection: process and rationale. | journal=BJU Int | year= 2013 | volume= 112 | issue= 5 | pages= 543-7 | pmid=23924423 | doi=10.1111/bju.12318 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23924423 }} </ref> | | According to the [[US Preventive Services Task Force|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 [[Rectal examination|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. |
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| ==Screening== | | ==Screening== |
| | Prostate cancer [[screening]] options include the [[Rectal examination|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.<ref name="pmid20664589">{{cite journal| author=Gupta A, Roobol MJ, Savage CJ, Peltola M, Pettersson K, Scardino PT et al.| title=A four-kallikrein panel for the prediction of repeat prostate biopsy: data from the European Randomized Study of Prostate Cancer screening in Rotterdam, Netherlands. | journal=Br J Cancer | year= 2010 | volume= 103 | issue= 5 | pages= 708-14 | pmid=20664589 | doi=10.1038/sj.bjc.6605815 | pmc=2938258 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20664589 }} </ref> |
| | * 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.<ref name="US life table 2003">{{cite journal |author=Arias E |month=April 19, |year=2006 |title=United States Life Tables, 2003 |journal=Natl Vital Stat Rep |volume=54 |issue=14 |pages=1–40 |pmid=16681183 |url=http://www.cdc.gov/nchs/data/nvsr/nvsr54/nvsr54_14.pdf|format=PDF}}</ref><ref name="pmid9314820">{{cite journal| author=von Eschenbach A, Ho R, Murphy GP, Cunningham M, Lins N| title=American Cancer Society guideline for the early detection of prostate cancer: update 1997. | journal=CA Cancer J Clin | year= 1997 | volume= 47 | issue= 5 | pages= 261-4 | pmid=9314820 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9314820 }} </ref><ref name="pmid17392386">{{cite journal| author=Smith RA, Cokkinides V, Eyre HJ| title=Cancer screening in the United States, 2007: a review of current guidelines, practices, and prospects. | journal=CA Cancer J Clin | year= 2007 | volume= 57 | issue= 2 | pages= 90-104 | pmid=17392386 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17392386 }} </ref> |
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| Prostate cancer [[screening (medicine)|screening]] is an attempt to find unsuspected cancers. Screening tests may lead to more specific follow-up tests such as a [[biopsy]], where small cores of the prostate are removed for closer study. Prostate cancer screening options include the [[Rectal examination|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.
| | * 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.<ref name="pmid23924423">{{cite journal| author=Carter HB| title=American Urological Association (AUA) guideline on prostate cancer detection: process and rationale. | journal=BJU Int | year= 2013 | volume= 112 | issue= 5 | pages= 543-7 | pmid=23924423 | doi=10.1111/bju.12318 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23924423}}</ref> |
| Prostate cancer is usually a slow-growing cancer, very common among older men. In fact, most prostate cancers never grow to the point where they cause symptoms, and most men with prostate cancer die of other causes before prostate cancer has an impact on their lives. The PSA screening test may detect these small cancers that would never become life threatening. Doing the PSA test in these men may lead to [[overdiagnosis]], including additional testing and treatment. Follow-up tests, such as [[prostate biopsy]], may cause pain, bleeding and infection. Prostate cancer treatments may cause urinary [[Urinary incontinence|incontinence]] and [[erectile dysfunction]]. Therefore, it is essential that the risks and benefits of diagnostic procedures and treatment be carefully considered before PSA screening.
| | 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.<ref name="Ross 2004">{{cite journal |author=Ross LE, Coates RJ, Breen N, Uhler RJ, Potosky AL, Blackman D |year=2004 |title=Prostate-specific antigen test use reported in the 2000 National Health Interview Survey |journal=Prev Med |volume=38 |issue=6 |pages=732–44 |pmid=15193893 | doi = 10.1016/j.ypmed.2004.01.005}}</ref> |
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| Several medical societies have not found sufficient evidence to support routine screening for prostate cancer - but the American Urological Association supports annual screening and digital examination for men over 50 years old - and starting earlier for 'men at high risk (those with a family history of prostate cancer or African American men)'. <ref>[http://www.auanet.org/content/guidelines-and-quality-care/policy-statements/e/early-detection-of-prostate-cancer.cfm ''Early Detection of Prostate Cancer'', American Urological Association, Washington, D.C., revised: October 2008].Accessed: 12-01-2008 </ref>
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| * In 2002, the [[US Preventive Services Task Force|U.S. Preventive Services Task Force]] (USPSTF) concluded that the evidence was insufficient to recommend for or against routine screening for prostate cancer using PSA testing or digital rectal examination (DRE).<ref name="USPSTF 2002">{{cite web |author=US Preventive Services Task Force |month=December |year=2002 |title=Screening for Prostate Cancer |publisher=Agency for Healthcare Research and Quality |url=http://www.ahrq.gov/clinic/uspstf/uspsprca.htm}}
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| {{cite journal |author=[[US Preventive Services Task Force|USPSTF]] |month=December 3, |year=2002 |title=Screening for prostate cancer: recommendation and rationale |journal=[[Annals of Internal Medicine|Ann Intern Med]] |volume=137 |issue=11 |pages=915–6 |pmid=12458992 |url=http://www.annals.org/cgi/reprint/137/11/915.pdf|format=PDF}}<br>
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| {{cite journal |author=Harris R, Lohr KN |month=December 3, |year=2002 |title=Screening for prostate cancer: an update of the evidence for the U.S. Preventive Services Task Force |journal=[[Annals of Internal Medicine|Ann Intern Med]] |volume=137 |issue=11 |pages=917–29 |pmid=12458993 |url=http://www.annals.org/cgi/reprint/137/11/917.pdf|format=PDF}}</ref> The previous 1995 USPSTF recommendation was against routine screening.
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| * In 1997, [[American Cancer Society]] (ACS) guidelines began recommending that beginning at age 50 (age 45 for African-American men and men with a family history of prostate cancer, and since 2001, age 40 for men with a very strong family history of prostate cancer), PSA testing and DRE be ''offered'' annually to men who have a life-expectancy of 10 or more years (average life expectancy is 10 years or more for U.S. men under age 76)<ref name="US life table 2003">{{cite journal |author=Arias E |month=April 19, |year=2006 |title=United States Life Tables, 2003 |journal=Natl Vital Stat Rep |volume=54 |issue=14 |pages=1–40 |pmid=16681183 |url=http://www.cdc.gov/nchs/data/nvsr/nvsr54/nvsr54_14.pdf|format=PDF}}</ref>along with information on the risks and benefits of screening.<ref name="ACS guidelines">{{cite journal |author=von Eschenbach A, Ho R, Murphy GP, Cunningham M, Lins N |month=September-October |year=1997 |title=American Cancer Society guideline for the early detection of prostate cancer: update 1997 |journal=CA Cancer J Clin |volume=47 |issue=5 |pages=261–4 |pmid=9314820 |url=http://caonline.amcancersoc.org/cgi/reprint/47/5/261.pdf |format=PDF|doi=10.3322/canjclin.47.5.261}}{{cite web |author=[[American Cancer Society|ACS]] |month=March 28, |year=2007 |title=Prostate Cancer: Early Detection |url=http://www.cancer.org/docroot/PED/content/PED_2_3X_ACS_Cancer_Detection_Guidelines_36.asp |accessdate=2007-11-19}}<br>
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| {{cite journal |author=Smith RA, Cokkinides V, Eyre HJ |month=March-April |year=2007 |title=Cancer screening in the United States, 2007: a review of current guidelines, practices, and prospects |journal=CA Cancer J Clin |volume=57 |issue=2 |pages=90–104 |pmid=17392386 |url=http://caonline.amcancersoc.org/cgi/reprint/57/2/90.pdf|format=PDF}}<br>
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| {{cite journal |author=Smith RA, Cokkinides V, Eyre HJ |month=January-February |year=2006 |title=American Cancer Society guidelines for the early detection of cancer, 2006 |journal=CA Cancer J Clin |volume=56 |issue=1 |pages=11–25 |pmid=16449183 |url=http://caonline.amcancersoc.org/cgi/reprint/57/2/90.pdf|format=PDF}}</ref> The previous ACS recommendations since 1980 had been for routine screening for prostate cancer with DRE annually beginning at age 40, and since 1992 had been for routine screening with DRE and PSA testing annually beginning at age 50.<ref name="ACS history">{{cite web |author=[[American Cancer Society|ACS]] |month=March 29, |year=2007 |title=Chronological History of ACS Recommendations on Early Detection of Cancer |url=http://www.cancer.org/docroot/PED/content/PED_2_3X_Chronological_History_of_ACS_Recommendations_on_Early_Detection_of_Cancer.asp}}</ref>
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| * 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. Biopsy is recommended if DRE is positive or PSA ≥ 4 ng/mL, and biopsy considered if PSA > 2.5 ng/mL or PSA velocity ≥ 0.35 ng/mL/year when PSA ≤ 2.5 ng/mL.<ref name="NCCN 2007">{{cite web |author=[[National Comprehensive Cancer Network|NCCN]] |month=May 10, |year=2007 |title=Prostate Cancer Early Detection V.2.2007 |work=NCCN Clinical Practice Guidelines in Oncology |url=http://www.nccn.org/professionals/physician_gls/PDF/prostate_detection.pdf|format=PDF}}</ref>
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| * Some U.S. radiation oncologists and medical oncologists who specialize in treating prostate cancer recommend obtaining a baseline PSA in all men at age 35.<ref name="D'Amico 2004">{{cite web |author= |month=July |year=2004 |title=Study suggests value of regular PSA tests for tracking prostate cancer |publisher=[[Dana-Farber Cancer Institute]] |url=http://www.hms.harvard.edu/news/pressreleases/df/0704prostate_test.html}}
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| {{cite journal |author=Kladko B |month=August 15, |year=2005 |title=Prostate cancer test gets another look |journal=The Boston Globe |url=http://www.boston.com/yourlife/health/men/articles/2005/08/15/prostate_cancer_test_gets_another_look/?page=full}}</ref> or beginning annual PSA testing in high risk men at age 35.<ref name="Strum 2005">{{cite journal |author=Strum SB, Pogliano D |month=May |year=2005 |title=What every doctor who treats male patients should know |journal=PCRI Insights |volume=8 |issue=2 |pages=4–5 |url=http://www.prostate-cancer.org/resource/pdf/Is8-2.pdf|format=PDF}}</ref>
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| * The American Urological Association Patient Guide to Prostate Cancer.<ref name="AUA Patient Guide 2008">{{cite web |author=American Urological Association (AUA) |year=2008 |title=Prostate Cancer Patient Guide |work=AUA Patient Guidelines |url=http://www.auanet.org/guidelines/patient_guides/pc08.pdf|format=PDF}}</ref>
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| 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.<ref name="Ross 2004">{{cite journal |author=Ross LE, Coates RJ, Breen N, Uhler RJ, Potosky AL, Blackman D |year=2004 |title=Prostate-specific antigen test use reported in the 2000 National Health Interview Survey |journal=Prev Med |volume=38 |issue=6 |pages=732–44 |pmid=15193893 | doi = 10.1016/j.ypmed.2004.01.005}}</ref>
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| However, because PSA screening is widespread in the United States, following the recommendations of major scientific and medical organizations to use shared decision-making is legally perilous in some U.S. states.<ref name="Lewis 2007">{{cite journal |author=Lewis MH, Gohagan JK, Merenstein DJ |year=2007 |title=The locality rule and the physician's dilemma: local medical practices vs the national standard of care |journal=[[Journal of the American Medical Association|JAMA]] |volume=297 |issue=23 |pages=2633–7 |pmid=17579232 |doi=10.1001/jama.297.23.2633}}</ref>
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| In 2003, a Virginia jury found a [[general practitioner#United States|family practice]] [[residency (medicine)|residency program]] guilty of [[medical malpractice|malpractice]] and liable for $1 million for following national [[medical guideline|guideline]]s and using shared decision-making, thereby allowing a patient (subsequently found to have a high PSA and incurable advanced prostate cancer) to decline a screening PSA test, instead of routinely ordering without discussion PSA tests in all men ≥ 50 years of age as four local physicians testified was their practice, and was accepted by the jury as the local [[standard of care]].<ref name="Mernstein 2004">{{cite journal |author=Merenstein D |year=2004 |title=Winners and losers |journal=[[Journal of the American Medical Association|JAMA]] |volume=291 |issue=1 |pages=15–6 |pmid=14709561 |doi=10.1001/jama.291.1.15}}</ref>
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| An estimated 20 million PSA tests are done per year in North America and possibly 20 million more outside of North America.<ref name="De Angelis 2007">{{cite journal |author=De Angelis G, Rittenhouse HG, Mikolajczyk SD, Blair Shamel L, Semjonow A |year=2007 |title=Twenty years of PSA: from prostate antigen to tumor marker |journal=Rev Urol |volume=9 |issue=3 |pages=113–23 |pmid=17934568 |url=http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=2002501&blobtype=pdf}}</ref>
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| * In 2000, 34.1% of all U.S. men age ≥ 50 had a ''screening'' PSA test within the past year and 56.8% reported ever having a PSA test.<ref name="Ross 2004"/>
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| * In 2000, 33.6% of all U.S. men age 50–64 and 51.3% of men age ≥ 65 had a PSA test within the past year.<ref name="Swan 2003">{{cite journal |author=Swan J, Breen N, Coates RJ, Rimer BK, Lee NC |year=2003 |title=Progress in cancer screening practices in the United States: results from the 2000 National Health Interview Survey |journal=Cancer |volume=97 |issue=6 |pages=1528–40 |pmid=12627518 |url=http://www3.interscience.wiley.com/cgi-bin/fulltext/103521394/PDFSTART |doi=10.1002/cncr.11208}}</ref>
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| * In 2005, 33.5% of all U.S. men age 50–64 had a PSA test in the past year.
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| ** 37.5% of men with private [[health insurance#Health insurance in the United States|health insurance]], 20.8% of men with Medicaid insurance, 14.0% of currently [[Health care in the United States#Inequities|uninsured]] men, and 11.5% of men uninsured for > 12 months.<ref name="Ward 2008">{{cite journal |author=Ward E, Halpern M, Schrag N, Cokkinides V, DeSantis C, Bandi P, Siegel R, Stewart A, Jemal A |month=Jan-Feb |year=2008 |title=Association of insurance with cancer care utilization and outcomes |journal=CA Cancer J Clin |volume=58 |issue=1 |pages=9–31 |url=http://caonline.amcancersoc.org/cgi/reprint/58/1/9.pdf |format=PDF|pmid=18096863 |doi=10.3322/CA.2007.0011}}</ref>
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| * In 2000–2001, 34.1% of all Canadian men age ≥ 50 had a ''screening'' PSA test within the past year and 47.5% reported ever having a ''screening'' PSA test.<ref name="Beaulac 2006">{{cite journal |author=Beaulac JA, Fry RN, Onysko J |year=2006 |title=Lifetime and recent prostate specific antigen (PSA) screening of men for prostate cancer in Canada |journal=Can J Public Health |volume=97 |issue=3 |pages=171–6 |pmid=16827400}}</ref>
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| * Canadian men in Ontario were most likely to have had a PSA test within the past year and men in Alberta were least likely to have had a PSA test with the past year or ever.<ref name="Gibbons 2003">{{cite journal |author=Gibbons L, Waters C |month=May |year=2003 |title=Prostate cancer--testing, incidence, surgery and mortality |journal=Health Rep |volume=14 |issue=3 |pages=9–20 |pmid=12816012 |url=http://www.statcan.ca/english/studies/82-003/archive/2003/14-3-a.pdf|format=PDF}}</ref>
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| ==Screening Methods==
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| ===Digital Rectal Examination===
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| [[Rectal examination|Digital rectal examination]] (DRE) is a procedure where the examiner inserts a gloved, lubricated finger into the rectum to check the size, shape, and texture of the prostate. Areas which are irregular, hard or lumpy need further evaluation, since they may contain cancer. Although the DRE only evaluates the back of the prostate, 85% of prostate cancers arise in this part of the prostate. Prostate cancer which can be felt on DRE is generally more advanced.<ref>{{cite journal| last=Chodak| first=GW| coauthors=Keller P, Schoenberg HW| title=Assessment of screening for prostate cancer using the digital rectal examination| journal=J Urol| year=1989| month=May| volume=141| issue=5| pages=1136–8| pmid=2709500}}</ref> The use of DRE has never been shown to prevent prostate cancer deaths when used as the only screening test.<ref>{{cite journal| last=Krahn| first=MD| coauthors=Mahoney JE, Eckman MH, Trachtenberg J, Pauker SG, Detsky AS| title=Screening for prostate cancer.. A decision analytic view| journal=JAMA| year=1994| month=September 14| volume=272| issue=10| pages=773–80| pmid=7521400| doi=10.1001/jama.272.10.773}}</ref>
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| ===Prostate Specific Antigen===
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| {{main|Prostate specific antigen}}
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| The PSA test measures the blood level of [[prostate-specific antigen]], an [[enzyme]] produced by the prostate. Specifically, PSA is a [[serine protease]] similar to [[kallikrein]]. Its normal function is to liquify gelatinous semen after ejaculation, allowing [[Spermatozoon|spermatozoa]] to more easily navigate through the uterine [[cervix]].
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| The risk of prostate cancer increases with increasing PSA levels.<ref name="Catalona 2007">{{cite web |author=Catalona WJ |month=August 16, |year=2007 |title=How I manage a patient with a newly elevated PSA |work=2007 [[Centers for Disease Control and Prevention|CDC]] Cancer Conference |url=http://www.cdccancerconference.net/Presentations/ET2.0/ET2.0_Catalona.pdf|format=PDF}}</ref> 4 ng/mL was chosen arbitrarily as a decision level for biopsies in the clinical trial upon which the [[Food and Drug Administration|FDA]] in 1994 based adding prostate cancer detection in men age 50 and over as an approved indication for the first commercially available PSA test.<ref name="Kolota 2004">{{cite journal |author=Kolota G |month=May 30, |year=2004 |title=It was medical gospel, but it wasn't true |journal=The New York Times |pages=4.7 |url=http://query.nytimes.com/gst/fullpage.html?res=9F05E5DD1E3EF933A05756C0A9629C8B63&sec=&spon=&pagewanted=all}}<br>
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| {{cite journal |author=Thompson IM, Pauler DK, Goodman PJ, Tangen CM, Lucia MS, Parnes HL, Minasian LM, Ford LG, Lippman SM, Crawford ED, Crowley JJ, Coltman CA Jr |month= May 27, |year=2004 |title=Prevalence of prostate cancer among men with a prostate-specific antigen level < or =4.0 ng per milliliter |journal=N Engl J Med |volume=350 |issue=22 |pages=2239–46 |pmid=15163773}}<br>
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| {{cite journal |author=Carter HB |month= May 27, |year=2004 |title=Prostate cancers in men with low PSA levels--must we find them? |journal=N Engl J Med |volume=350 |issue=22 |pages=2292–4 |pmid=15163780 |doi=10.1056/NEJMe048003}}<br>
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| {{cite journal |author=Catalona WJ, Richie JP, Ahmann FR, Hudson MA, Scardino PT, Flanigan RC, deKernion JB, Ratliff TL, Kavoussi LR, Dalkin BL, et al. |month= May |year=1994 |title=Comparison of digital rectal examination and serum prostate specific antigen in the early detection of prostate cancer: results of a multicenter clinical trial of 6,630 men |journal=J Urol |volume=151 |issue=5 |pages=1283–90 |pmid=7512659}}<br>
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| {{cite web |author=[[Food and Drug Administration|FDA]] |month=August 29, |year=1994 |title=FDA approves test for prostate cancer |url=http://www.fda.gov/bbs/topics/ANSWERS/ANS00598.html}}</ref>
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| 4 ng/mL was used as the biopsy decision level in the [[Prostate cancer screening#Randomized controlled trials|PLCO]] trial, 3 ng/mL was used in the [[Prostate cancer screening#Randomized controlled trials|ERSPC]] and [[Prostate cancer screening#Randomized controlled trials|ProtecT]] trials, and 2.5 ng/mL is used in the 2007 NCCN guideline.
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| PSA levels can change for many reasons other than cancer. Two common causes of high PSA levels are enlargement of the prostate ([[benign prostatic hypertrophy]] (BPH)) and infection in the prostate ([[prostatitis]]). It can also be raised for 24 hours after ejaculation and several days after catheterization. PSA levels are lowered in men who use medications used to treat BPH or [[baldness]]. These medications, [[finasteride]] (marketed as Proscar or Propecia) and [[dutasteride]] (marketed as Avodart), may decrease the PSA levels by 50% or more.
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| Several other ways of evaluating the PSA have been developed to avoid the shortcomings of simple PSA screening. The use of age-specific reference ranges improves the sensitivity and specificity of the test. The rate of rise of the PSA over time, called the PSA velocity, has been used to evaluate men with PSA levels between 4 and 10 ng/ml, but it has not proven to be an effective screening test.<ref>{{cite journal| last=Roobol| first=MJ| coauthors=Kranse R, de Koning HJ, Schroder FH| title=Prostate-specific antigen velocity at low prostate-specific antigen levels as screening tool for prostate cancer: results of second screening round of ERSPC (ROTTERDAM)| journal=Urology| year=2004| month=February| volume=63| issue=2| pages=309–13; discussion 313–5| pmid=14972478| doi=10.1016/j.urology.2003.09.083}}</ref> Comparing the PSA level with the size of the prostate, as measured by [[Medical ultrasonography|ultrasound]] or [[magnetic resonance imaging]], has also been studied. This comparison, called PSA density, is both costly and has not proven to be an effective screening test.<ref>{{cite journal| last=Catalona| first=WJ| coauthors=Richie JP, deKernion JB, Ahmann FR, Ratliff TL, Dalkin BL, Kavoussi LR, MacFarlane MT, Southwick PC| title=Comparison of prostate specific antigen concentration versus prostate specific antigen density in the early detection of prostate cancer: receiver operating characteristic curves| journal=J Urol| year=1994| month=December| volume=152| issue=6 Pt 1| pages=2031–6| pmid=7525994}}</ref> PSA in the blood may either be free or bound to other [[protein]]s. Measuring the amount of PSA which is free or bound may provide additional screening information, but questions regarding the usefulness of these measurements limit their widespread use.<ref>{{cite journal| last=Hoffman| first=RM| coauthors=Clanon DL, Littenberg B, Frank JJ, Peirce JC| title=Using the free-to-total prostate-specific antigen ratio to detect prostate cancer in men with nonspecific elevations of prostate-specific antigen levels| journal=J Gen Intern Med| year=2000| month=October| volume=15| issue=10| pages=739–48| pmid=11089718| doi=10.1046/j.1525-1497.2000.90907.x}}</ref><ref>{{cite journal| last=Partin| first=AW| coauthors=Brawer MK; Bartsch G; Horninger W; Taneja SS; Lepor H; Babaian R; Childs SJ; Stamey T; Fritsche HA; Sokoll L; Chan DW; Thiel RP; Cheli CD| title=Complexed prostate specific antigen improves specificity for prostate cancer detection: results of a prospective multicenter clinical trial| journal=J Urol| year=2003| month=November| volume=170| issue=5| pages=1787–91| pmid=14532777| doi=10.1097/01.ju.0000092695.55705.dd}}</ref>
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| ==Interpreting the results of Screening Tests==
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| Two [[clinical prediction rule]]s help predict the probability of cancer based on the the level of the [[prostate-specific antigen]] and other [[medical sign|clinical findings]].<ref name="pmid17704405">{{cite journal |author=Nam RK, Toi A, Klotz LH, ''et al'' |title=Assessing individual risk for prostate cancer |journal=J. Clin. Oncol. |volume=25 |issue=24 |pages=3582–8 |year=2007 |pmid=17704405 |doi=10.1200/JCO.2007.10.6450}}</ref><ref name="pmid16622122">{{cite journal |author=Thompson IM, Ankerst DP, Chi C, ''et al'' |title=Assessing prostate cancer risk: results from the Prostate Cancer Prevention Trial |journal=J. Natl. Cancer Inst. |volume=98 |issue=8 |pages=529–34 |year=2006 |pmid=16622122 |doi=10.1093/jnci/djj131}} [http://www.compass.fhcrc.org/edrnnci/bin/calculator/main.asp?t=prostate&sub=disclaimer&v=prostate&m=&x=Prostate%20Cancer Online calculator]</ref>
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| ==Evidence for Efficacy==
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| ===Randomized Controlled Trials===
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| One [[randomized controlled trial]] found significant reduction in death from screening.<ref name="pmid9973093">{{cite journal |author=Labrie F, Candas B, Dupont A, ''et al'' |title=Screening decreases prostate cancer death: first analysis of the 1988 Quebec prospective randomized controlled trial |journal=Prostate |volume=38 |issue=2 |pages=83-91 |year=1999 |pmid=9973093 |doi=}}</ref> However, the [[intention to treat analysis]] showed no benefit.
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| A [[Secondary data|secondary analysis]] of a [[randomized controlled trial]] suggests screening for prostate cancer every 4 years is adequate. The screening comprises a PSA blood test, a digital rectal exam, and a transrectal ultrasound. "Very few, if any, aggressive prostate cancers escape (this) screening."<ref name="pmid16006878">{{cite journal | author = Schröder F, Raaijmakers R, Postma R, van der Kwast T, Roobol M | title = 4-year prostate specific antigen progression and diagnosis of prostate cancer in the European Randomized Study of Screening for Prostate Cancer, section Rotterdam. | journal = J Urol | volume = 174 | issue = 2 | pages = 489-94; discussion 493-4 | year = 2005 | id = PMID 16006878}}</ref>
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| When all available trials are meta-analyzed, mortality from prostate cancer may be reduced among patients with sufficient duration of screening (see [http://www.wikidoc.org/index.php/File:Outcome-Primary.png Forest plot]) .<ref> Prostate cancer screening with prostate specific antigen: a living systematic review. GitHub. Available at http://openmetaanalysis.github.io/Prostate-cancer-screening-with-prostate-specific-antigen/. Accessed June 14, 2015</ref>
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| [[Image:Outcome-Primary.png|400px]]
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| ===Decision Analyses===
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| In the absence of well done [[randomized controlled trials]], a [[decision analysis]] can estimate the benefit of screening. <ref name="pmid7521400">{{cite journal |author=Krahn MD, Mahoney JE, Eckman MH, Trachtenberg J, Pauker SG, Detsky AS |title=Screening for prostate cancer. A decision analytic view |journal=JAMA |volume=272 |issue=10 |pages=773-80 |year=1994 |pmid=7521400 |doi=}}</ref><ref name="pmid10989402">{{cite journal |author=Ross KS, Carter HB, Pearson JD, Guess HA |title=Comparative efficiency of prostate-specific antigen screening strategies for prostate cancer detection |journal=JAMA |volume=284 |issue=11 |pages=1399-405 |year=2000 |pmid=10989402 |doi=|url=http://jama.ama-assn.org/cgi/content/full/284/11/1399}}</ref> One analysis found that approximately 303 men would [[number needed to treat | number need to be screen]]ed with a "strategy of PSA testing at ages 40 and 45 years followed by biennial testing beginning at age 50" to prevent one death from prostate cancer.<ref name="pmid10989402"/>
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| ==Clinical Practice Guidelines==
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| [[clinical_practice_guideline | Clinical practice guidelines]] for prostate cancer [[screening (medicine)|screening]] are controversial because the benefits of screening may not outweigh the risks of follow-up diagnostic tests and cancer treatments:
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| * [http://www.ahrq.gov/clinic/uspstfix.htm U.S. Preventive Services Task Force (USPSTF)]:<ref name="pmid12458992">{{cite journal |author=U.S. Preventive Services Task Force | title=Screening for prostate cancer: recommendation and rationale |journal=Ann. Intern. Med. |volume=137 |issue=11 |pages=915-6 |year=2002 |pmid=12458992 |doi=|url=http://www.annals.org/cgi/content/full/137/11/915}}</ref><ref name="pmid12458993">{{cite journal |author=Harris R, Lohr KN |title=Screening for prostate cancer: an update of the evidence for the U.S. Preventive Services Task Force |journal=Ann. Intern. Med. |volume=137 |issue=11 |pages=917-29 |year=2002 |pmid=12458993 |doi=|url=http://www.annals.org/cgi/content/full/137/11/917}}</ref><ref>{{cite web | author=U.S. Preventive Services Task Force | title= Screening for Prostate Cancer | url=http://www.ahcpr.gov/clinic/uspstf/uspsprca.htm#related | date=December 2002) | accessdate=2006-09-14}}</ref>
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| :"the evidence is insufficient to recommend for or against routine screening for prostate cancer using prostate-specific antigen (PSA) testing or digital rectal examination (DRE). This is a [http://www.ahrq.gov/clinic/3rduspstf/ratings.htm grade I recommendation]"
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| * [[American Cancer Society]], in 2001, recommended:<ref name="pmid11577479">{{cite journal |author=Smith RA, von Eschenbach AC, Wender R, ''et al'' |title=American Cancer Society guidelines for the early detection of cancer: update of early detection guidelines for prostate, colorectal, and endometrial cancers. Also: update 2001--testing for early lung cancer detection |journal=CA: a cancer journal for clinicians |volume=51 |issue=1 |pages=38-75; quiz 77-80 |year=2001 |pmid=11577479 |doi=|url=http://caonline.amcancersoc.org/cgi/content/full/51/1/38#SEC4}}</ref><ref>{{cite web | author = National Guideline Clearinghouse | title=Recommendations from the American Cancer Society Workshop on Early Prostate Cancer Detection | url=http://www.guideline.gov/summary/summary.aspx?doc_id=2747&nbr=001973 | accessdate=2006-09-14}}</ref><ref>{{cite web | author = American Cancer Society | title = What the American Cancer Society Recommends | url=http://www.cancer.org/docroot/CRI/content/CRI_2_2_3X_How_is_prostate_cancer_found_36.asp?sitearea= | accessdate=2007-01-16}}</ref>
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| :"The PSA test and the DRE should be offered annually beginning at age 50 to men who have a life expectancy of at least 10 years. Men at high risk should begin testing at age 45. Information should be provided to patients about benefits and limitations of testing."
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| The ACS recommends that individual men discuss the potential benefits and risks of testing with their doctors in order to make an informed decision on whether or not to be tested. Screening should be offered annually to African-American men and those with a family history of prostate cancer upon reaching 45 years. Other racial and ethnic groups, such as Asian- and Hispanic-Americans have a lower risk of prostate cancer, and may not benefit from screening. Screening is likely not useful for men over age 70 or with other significant medical problems and a life expectancy of fewer than 10 years.
| | '''Benefits''' |
| | *[[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.<ref name="”cancergov”">Prostate Cancer Screening. Physician Data Query Database 2015. http://www.cancer.gov/types/prostate/hp/prostate-screening-pdq </ref> |
| | '''Harms''' |
| | *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. |
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| | ===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.<ref>Kasivisvanathan V, Rannikko AS, Borghi M, Panebianco V, Mynderse LA, Vaarala MH, et al. MRI-Targeted or Standard Biopsy for Prostate-Cancer Diagnosis. New England Journal of Medicine. 2018 Mar 18;0(0):. {{doi|10.1056/NEJMoa1801993}}</ref><ref name="pmid28762124">{{cite journal| author=Auvinen A, Rannikko A, Taari K, Kujala P, Mirtti T, Kenttämies A et al.| title=A randomized trial of early detection of clinically significant prostate cancer (ProScreen): study design and rationale. | journal=Eur J Epidemiol | year= 2017 | volume= 32 | issue= 6 | pages= 521-527 | pmid=28762124 | doi=10.1007/s10654-017-0292-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28762124 }} </ref> |
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| ==References== | | ==References== |
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| | [[Category:Medicine]] |