Summary of Recommendation
The U.S. Preventive Services Task Force
(USPSTF) concludes that 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). Rating: I recommendation.
Clinical Considerations:
*Prostate specific antigen (PSA) testing and digital rectal examination (DRE) can effectively detect prostate cancer in its early pathologic stages. Recent evidence suggests that radical prostatectomy can reduce prostate cancer mortality in men whose
cancer is detected clinically. The balance of potential benefits (the reduction of morbidity and
mortality from prostate cancer) and harms (falsepositive results, unnecessary biopsies, and possible complications) of early treatment of the types of cancers found by screening, however, remains uncertain. Therefore, the benefits of screening for early prostate cancer remain unknown. Ongoing screening trials, and trials of treatment versus “watchful waiting” for cancers detected by screening, may help clarify the benefits of early detection of prostate cancer.
*Despite the absence of firm evidence of effectiveness, some clinicians may opt to perform
prostate cancer screening for other reasons. Given the uncertainties and controversy surrounding prostate cancer screening, clinicians should not order the PSA test without first discussing with the patient the potential but uncertain benefits and the possible harms of prostate cancer screening. Men should be informed of the gaps in the evidence, and they should be assisted in considering their personal preferences and risk profile before deciding whether
to be tested.
*If early detection improves health outcomes, the population most likely to benefit from screening will be men aged 50 to 70 who are at average risk, and men older than 45 who are at increased risk (African American men and men with a family history of a first-degree relative with prostate cancer).1 Benefits may be smaller in Asian Americans, Hispanics, and other racial and ethnic groups that have a lower risk of prostate cancer.
Older men and men with other significant medical problems who have a life expectancy of fewer than10 years are unlikely to benefit from screening.
*PSA testing is more sensitive than DRE for the detection of prostate cancer. PSA screening with the conventional cut-point of 4.0 ng/ml detects a large majority of prostate cancers; however, a significant percentage of early prostate cancers (10% to 20%) will be missed by PSA testing alone. Using a lower threshold to define an abnormal PSA detects more cancers at the cost of more false positives and more Screening for Prostate Cancer biopsies. The yield of screening in terms of cancer detected declines rapidly with repeated annual testing.
If screening were to reduce mortality, biennial PSA screening could yield as much benefit as annual screening.
References
1. Harris RP, Lohr KN. Screening for prostate cancer: an
update of the evidence for the U.S. Preventive Services
Task Force. Ann Intern Med. 2002; 137:917-929.
2. Harris RP, Lohr KN, Beck R, Fink K, Godley P, Bunton
A. Screening for Prostate Cancer. Systematic Evidence
Review No. 16 (Prepared by the Research Triangle
Institute-University of North Carolina Evidence-based
Practice Center under Contract No. 290-97-0011).
Rockville, MD: Agency for Healthcare Research and
Quality. December 2001. (Available on the AHRQ Web
site at: www.ahrq.gov/clinic/serfiles.htm).
This USPSTF recommendation was first published in:
Ann Intern Med. 2002;137:915-916.
Si lo quieren completo lo pueden ver en http://www.ahrq.gov/clinic/uspstf/uspstopics.htm.
Aqui lo que recomiendan en Up to date bastante actualizado:
| Screening for prostate cancer | ||
 | ||
| Author Richard M Hoffman, MD, MPH | Section Editor Robert H Fletcher, MD, MSc | Deputy Editor David M Rind, MD |
Last literature review version 16.2: mayo 2008 This topic last updated: mayo 22, 2008 (More)
SUMMARY AND RECOMMENDATIONS — It is unclear whether screening for prostate cancer reduces morbidity or mortality, and whether even if it does so, the benefits of screening outweigh potential harms to quality of life.
Given the lack of conclusive evidence of benefits of screening from randomized trials, some suggestive evidence of benefits from observational trials, and the potential harms associated with screening, we feel that individual patient preferences for certain health outcomes are usually a deciding factor in determining whether or not screening for prostate cancer is appropriate in that patient:
- Discussions of screening for prostate cancer should present patients with information on the risks and benefits of screening, such as those in the summary points suggested by the American College of Physicians that are discussed above (see "Informed consent" above). Using existing written or video decision aids may help ensure that patients receive consistent, complete, and objective information and may optimize the time spent discussing screening during a clinic visit.
- Health care providers should discuss prostate cancer screening each year with men who are expected to live at least 10 years and are old enough to be at significant risk for prostate cancer. We suggest that discussions begin at age 50 in average risk white men and at age 40 to 45 in black men, men with a positive family history, and men who are known or likely to have the BRCA1 mutation (Grade 2C). (See "Age to begin screening" above).
- When a decision is made to screen, we suggest that annual screening be performed with digital rectal examination (DRE) and prostate specific antigen (PSA) tests (Grade 2C) (see "Frequency and method of screening" above):
- We suggest that screening be performed until comorbidities or age (75 years) limit life expectancy to less than 10 years or the patient decides against further screening (Grade 2C). Stopping screening at age 65 may be appropriate if the PSA level is less than 1.0 ng/mL. (See "Stopping screening" above).
- Men with an abnormal DRE or PSA level above 7 ng/mL should be referred for transrectal ultrasound-guided prostate biopsy without further testing. (See "Referrals for biopsy" above).
- We suggest that men with a PSA level between 4 ng/mL and 7 ng/mL undergo repeat testing several weeks later (Grade 2C). Prior to repeat PSA testing, men should abstain from ejaculation and bike riding for at least 48 hours. Men with prostatitis should be treated with antibiotics before retesting. Men with a repeat PSA level above 4 ng/mL should be referred for transrectal ultrasound-guided prostate biopsy. (See "Referrals for biopsy" above).
- Men with a PSA below 4.0 ng/mL and a normal DRE should not normally undergo biopsy. However, we suggest that men who experience a rise in PSA level of more than 0.75 ng/mL/year (based on at least three measurements obtained over 12 to 24 months) be referred for biopsy (Grade 2C). (See "Referrals for biopsy" above).
- We suggest that men with negative extended biopsies (biopsies performed using an extended protocol as opposed to just sextant biopsies) resume routine screening (Grade 2C). (See "Repeat biopsies" above).
