Early Detection Prostate Cancer

Question 1

What is the recommendation for PSA screening in men under age 40 years?

Answer 1

The Panel recommends against PSA screening in men under age 40 years.

Question 2

What is the prevalence of prostate cancer in men under age 40 years?

Answer 2

The prevalence of prostate cancer in men under age 40 years is extremely low, about 0.1%.

Question 3

Are there any data available to estimate the benefit of prostate cancer screening in men under age 40 years?

Answer 3

No, there are no data available to estimate the benefit of prostate cancer screening in men under age 40 years as none of the prospective randomized studies evaluating the benefits of PSA-based screening included men under age 40 years.

Question 4

What are the harms of PSA screening in men under age 40 years?

Answer 4

The harms of PSA screening in men under age 40 years include the side effects of diagnostic biopsies and perhaps subsequent treatment.

Question 5

Why is screening discouraged for men under age 40 years?

Answer 5

Screening is discouraged for men under age 40 years due to the relatively low prevalence of clinically detectable prostate cancer in this age group, the absence of any evidence demonstrating benefits of screening, and the known harms of screening.

Question 6

Does the panel recommend routine PSA screening for men between the ages of 40 to 54 years?

Answer 6

No, the panel does not recommend routine screening for men between the ages of 40 to 54 years who are at average risk.

Question 7

What is the evidence for the benefits of PSA screening in men under the age of 55 years?

Answer 7

There is no high-quality evidence to support the benefits of PSA screening in men under the age of 55 years. The two large randomized clinical trials did not include men under the age of 55 years, so they do not inform the decision.

Question 8

What is the reason for the panel’s recommendation against routine screening in men between the ages of 40 to 54 years?

Answer 8

The panel’s recommendation is based on the relatively low benefits and high harms of screening in this population. The harms of screening in this age group are at least equal to the benefits, if not higher.

Question 9

Are there any subgroups of men who may benefit from earlier screening?

Answer 9

Yes, there may be subgroups of men who are at higher risk, such as African American men and those with a family history of metastatic or lethal adenocarcinomas. For such men, decisions regarding prostate cancer screening should be individualized.

Question 10

Does the panel’s recommendation imply that there is absolutely no benefit to screening men between the ages of 40 to 54 years?

Answer 10

No, the panel’s recommendation does not imply that there is absolutely no benefit to screening this age group. It just means that the significant harms associated with screening likely outweigh the benefits.

Question 11

What is the recommendation for men ages 55 to 69 years regarding PSA screening?

Answer 11

The Panel recommends shared decision-making for men ages 55 to 69 years that are considering PSA screening, and proceeding based on men’s values and preferences.

Question 12

What is the benefit of PSA screening for men ages 55 to 69 years?

Answer 12

There is moderate evidence for the benefit of PSA screening in this age group, which includes a relative risk reduction of 21% in prostate cancer-specific death according to the ERSPC study at a median follow-up of 11 years.

Question 13

What should be considered during the shared decision-making process for men ages 55 to 69 years considering PSA screening?

Answer 13

The shared decision-making process should consider the man’s individual life expectancy, baseline mortality risk from other co-morbid conditions, individual risk for prostate cancer given their race/ethnicity and family history, and the degree to which screening might influence their overall life expectancy and chance of experiencing morbidity from prostate cancer or its treatment.

Question 14

What other approaches can be considered for prostate biopsy decisions in men with a suspicious PSA level?

Answer 14

Novel markers, imaging, and/or risk calculators can be considered for prostate biopsy decisions in men with a suspicious PSA level to inform biopsy decisions.

Question 15

What is the guideline statement for screening interval in men who have decided on screening through shared decision-making?

Answer 15

The guideline statement for screening interval in men who have decided on screening through shared decision-making is that a routine screening interval of two years or more may be preferred over annual screening.

Question 16

What is the evidence for the preference of a two-year screening interval?

Answer 16

The evidence for the preference of a two-year screening interval is mostly based on modeling studies and some evidence from randomized trials. Modeling studies have projected that screening men every two years preserves the majority of lives saved compared to annual screening while reducing the number of tests, false positive tests, and overdiagnosis.

Question 17

What does the ERSPC trial suggest about the comparison between a two-year screening interval and an annual screening interval?

Answer 17

The ERSPC trial suggests that a two-year screening interval significantly reduced the incidence of advanced disease compared to annual screening.

Question 18

What does the PLCO trial suggest about the comparison between a two-year screening interval and annual screening?

Answer 18

The PLCO trial suggests that there is little benefit from screening more frequently than every two years as prostate cancer mortality rates were similar in the two groups through 13 years of follow-up.

Question 19

What did Martin et al. find about the effect of a single PSA screening on prostate cancer detection and mortality?

Answer 19

Martin et al. found that while there was a higher proportion of men diagnosed with prostate cancer in the intervention group (screened group), there was no significant difference in prostate cancer mortality after a median follow-up of 10 years between the intervention group and the control group

Question 20

What is the guideline statement for men over age 70 years regarding PSA screening?

Answer 20

The Panel does not recommend routine PSA screening in men over age 70 years or any man with less than a 10 to 15 year life expectancy.

Question 21

What is the rationale for not recommending routine PSA screening for men over age 70 years?

Answer 21

The rationale for this recommendation is based on the absence of evidence of a screening benefit in this population with clear evidence of harms. Men over age 70 years have a higher competing mortality compared to younger men, and no compelling evidence of a treatment benefit, especially in men with a limited life expectancy below 10 to 15 years.

Question 22

What is the likelihood of overdiagnosis in men over age 70 years?

Answer 22

The likelihood of overdiagnosis increases as men age and is particularly high for older men with low-risk disease. Modeling studies of overdiagnosis in the US population have estimated that among men aged 70 to 79 years, half or more of cases detected by PSA screening with PSA less than 10 and Gleason score 6 or below are overdiagnosed. Among men over age 80 years, three-fourths or more of cases detected by PSA screening with PSA less than 10 and Gleason score 6 or below are overdiagnosed.