Academy of Diagnostics & Laboratory Medicine - Scientific Short

Prostate Cancer: To Screen or Not to Screen?

David Alter and Bob Dufour with special mention to George Birdsong for his comments

This Scientific Short provides an update to a previous Short published in 2011, linked here. While the 2011 Short is of historical interest, it reflects guidelines that are no longer current. The Short below provides for current recommendations on this topic.

In May 20181,2, the U.S. Preventive Services Task Force (USPSTF) revised its 2012 guidance relating to screening for prostate cancer with PSA, in which they made the following recommendations with commentary:

Age 55 – 69 years old Age >70 years old
The decision to be screened for prostate cancer should be an individual one.

Grade: C
Do not screen for prostate cancer.

Grade: D
Before deciding whether to be screened, men aged 55 to 69 years should have an opportunity to discuss the potential benefits and harms of screening with their clinician and to incorporate their values and preferences in the decision. Screening offers a small potential benefit of reducing the chance of death from prostate cancer in some men. However, many men will experience potential harms of screening, including false-positive results that require additional testing and possible prostate biopsy; overdiagnosis and overtreatment; and treatment complications, such as incontinence and erectile dysfunction. Harms are greater for men 70 years and older. In determining whether this service is appropriate in individual cases, patients and clinicians should consider the balance of benefits and harms on the basis of family history, race/ethnicity, comorbid medical conditions, patient values about the benefits and harms of screening and treatment-specific outcomes, and other health needs. Clinicians should not screen men who do not express a preference for screening and should not routinely screen men 70 years and older.
C- The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small.

D- The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.

(This table has been directly excerpted from references #1 and #2.)

These recommendations brought the USPSTF in line with existing statements from the American Cancer Society (ACS), American College of Physicians (ACP), American Urologic Association (AUA), and many other organizations by their agreement that “to screen or not” should be based on discussions between an individual and their physician about the risks and benefits of detecting prostate cancer early3 as well as including age cutoff when screening was no longer recommended.

Prostate cancer is the most common internal cancer in men, and the second most common cause of cancer death.  Autopsy studies done before screening became widespread found that prostate cancer was extremely common as men aged; 75% of men in their 80’s had prostate cancer. In a landmark study in Scandinavia, 223 men with early prostate cancer (mostly in their 60’s and 70’s at diagnosis) were followed for 21 years without treatment. At the end of that time, only 9% of the men were still alive. Most of the prostate cancers caused little harm during the first 10-15 years after diagnosis, but became progressively more widespread after that time in the 49 men who were still alive. This study pointed out the slow progression of prostate cancer, and the need for long follow-up to show any benefits from detecting prostate cancer early. Only 35 men died of prostate cancer, while 168 died of other causes4.

Screening with prostate specific antigen (PSA) has clearly reduced the incidence of metastatic disease and prostate cancer mortality. However, most prostate cancer is indolent and does no harm; so the question becomes: does the benefit of screening the entire adult male population regardless of age or symptoms outweigh the risks incurred by unnecessary treatments such as urinary/fecal incontinence, erectile dysfunction as well as, infection, hemorrhage and death.3, 5-7 This risk/benefit debate continues to dominate the discussion whether or not to screen for prostate cancer with passionate opinions on both sides. In counterpoint, the indolence of the cancer, supports the use of active surveillance to identify either a rapid rate of change in PSA or a significant increase in PSA over time for further evaluation.

At this point in time, 3,7 the differing organizations have come very close with their recommendations; namely, a gradual move from extreme positions of either screening all men >45 vs questioning the utility of screening to a shared decision making approach between patient and provider factoring in any possible underlying risk factors. Underlying important risk factors include older age, family history of prostate cancer and African-American race. With respect to African American race as a risk factor; it is well established that African American men are twice as likely dying from prostate cancer than non-Hispanic White Men. However, it is not well established that race itself is the risk factor. The “why” has not been well studied; however, the literature indicates that other factors such as diet, environmental factors and access to healthcare may be contributory8 9.

REFERENCES

  1. United States Preventive Services Task Force (USPTF) Prostate Cancer: Screening May 8, 2018 https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/prostate-cancer-screening accessed 6/30/2021
  2. US Preventive Services Task Force, Grossman DC, Curry SJ, Owens DK, Bibbins-Domingo K, Caughey AB, Davidson KW, Doubeni CA, Ebell M, Epling JW Jr, Kemper AR, Krist AH, Kubik M, Landefeld CS, Mangione CM, Silverstein M, Simon MA, Siu AL, Tseng CW. Screening for Prostate Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2018 May 8;319(18):1901-1913.
  3. Filella X, Albaladejo MD, Allué JA, Castaño MA, Morell-Garcia D, Ruiz MÀ, Santamaría M, Torrejón MJ, Giménez N. Prostate cancer screening: guidelines review and laboratory issues. Clin Chem Lab Med. 2019 Sep 25;57(10):1474-1487
  4. Johansson J-E, Andrén O, Andersson S-O, Dickman PW, Holmberg L, Magnuson A, et al. Natural History of Early, Localized Prostate Cancer. JAMA: The Journal of the American Medical Association 2004;291:2713-2719.
  5. Carlsson SV, Lilja H. Perspective on Prostate Cancer Screening. Clin Chem. 2019 Jan;65(1):24-27
  6. Catalona WJ. Prostate Cancer Screening. Med Clin North Am. 2018 Mar;102(2):199-214.
  7. Fenton JJ, Weyrich MS, Durbin S, Liu Y, Bang H, Melnikow J. Prostate-Specific Antigen-Based Screening for Prostate Cancer: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2018 May 8;319(18):1914-1931
  8. Siegel DA, O'Neil ME, Richards TB, Dowling NF, Weir HK. Prostate Cancer Incidence and Survival, by Stage and Race/Ethnicity - United States, 2001-2017. MMWR Morb Mortal Wkly Rep. 2020 Oct 16;69(41):1473-1480
  9. Riviere P, Luterstein E, Kumar A, Vitzthum LK, Deka R, Sarkar RR, Bryant AK, Bruggeman A, Einck JP, Murphy JD, Martínez ME, Rose BS. Survival of African American and non-Hispanic white men with prostate cancer in an equal-access health care system. Cancer. 2020 Apr 15;126(8):1683-1690

Academy of Diagnostics & Laboratory Medicine Designation

Fellows of the Academy use the designation of FADLM. This designation is equivalent to FACB and FAACC, the previous designations used by fellows of the National Academy of Clinical Biochemistry and AACC Academy. Those groups were rebranded as Academy of Diagnostics & Laboratory Medicine in 2023.