Prostate Cancer - Screening

Question 1

index patient 1: +/- 40 yo

Answer 1

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

• In this age group, there is a low prevalence of clinically detectable prostate cancer, no evidence demonstrating benefit of screening, and likely the same harms of screening as in other age groups.
• None of the prospective randomized studies evaluating the benefits of PSA based screening for prostate cancer included men under age 40 years. Hence there are no data available to estimate the benefit of prostate cancer screening in this population. However, the harms that can accrue from screening, which include the side effects of diagnostic biopsies and perhaps subsequent treatment will certainly apply to men in this age group who would be subject to screening. Therefore, due to the relatively low prevalence of clinically detectable prostate cancer in men below age 40 years, the absence of any evidence demonstrating benefits of screening and the known harms, screening is discouraged for men under age 40 years of age.

Question 2

Index patient 2: 40-54 yo

Answer 2

The Panel does not recommend routine screening in men between ages 40 to 54 years at average risk.

• For men younger than age 55 years at higher risk (e.g., positive family history or African American race), decisions regarding prostate cancer screening should be individualized.
• Given the Panel’s interpretation of the evidence concerning the benefits and harms of annual screening in men age 40 to 54 years who are not at an increased risk for prostate cancer and the rarity of fatal prostate cancers arising in this age group, the Panel does not recommend this practice as a routine. The Panel recognizes that certain subgroups of men age 40 to 54 years may realize added benefit from earlier screening. For example, men at increased risk for prostate cancer, such as those with a strong family history or those of African-American race, may benefit from earlier detection, given their higher incidence of disease
• The Panel recognizes that there may be other benefits associated with screening that were not considered or have not been demonstrated by the current literature. The “absence of evidence does not constitute evidence of absence” and, as such, the Panel is not explicitly stating that screening should be actively discouraged in this group of patients. The literature in this area is quite dynamic and future studies may document additional benefits in this younger population.

Question 3

Index patient 3: 55-69 yo

Answer 3

• For men ages 55 to 69 years the Panel recognizes that the decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality in 1 man for every 1,000 men screened over a decade against the known potential harms associated with screening and treatment. For this reason, the Panel strongly recommends shared decision-making for men age 55 to 69 years that are considering PSA screening, and proceeding based on men’s values and preferences.
• The greatest benefit of screening appears to be in men ages 55 to 69 years.
• Although there are considerable harms associated with screening, the Panel felt that in men age 55 to 69 years, there was sufficient certainty that the benefits of screening could outweigh the harms that a recommendation of shared decision-making in this age group was justified. The Panel believes that the test should not be offered in a setting where this is not practical, for example community-based screening by health systems or other organizations.
• Shared decision making should include a discussion of the man’s baseline mortality risk from other co-morbid conditions, his individual risk for prostate cancer, given his race/ethnicity and family history, and the degree to which screening might influence his overall life expectancy and chance of experiencing morbidity from prostate cancer or its treatment.
• To reduce the harms of screening, a routine screening interval of two years or more may be preferred over annual screening in those men who have participated in shared decision-making and decided on screening. As compared to annual screening, it is expected that screening intervals of two years preserve the majority of the benefits and reduce overdiagnosis and false positives.
• Additionally, intervals for rescreening can be individualized by a baseline PSA level.
• Modeling studies have projected that screening men every two years preserves the majority (at least 80%) of lives saved compared with annual screening while materially reducing the number of tests, the chance of a false positive test and overdiagnosis. This is supported by indirect evidence from the two largest screening trials, although there is no direct evidence from these trials supporting a specific screening interval.

Question 4

Index patient 4: 70 yo +

Answer 4

• The Panel does not recommend routine PSA screening in men age 70+ years or any man with less than a 10 to 15 year life expectancy.
• Some men age 70+ years who are in excellent health may benefit from prostate cancer screening.
• The Panel recognizes that men age 70+ years can have a life-expectancy over 10 to 15 years , and that a small subgroup of men age 70+ years who are in excellent health may benefit from PSA screening, but evidence to support the magnitude of benefit in this age group is extremely limited. 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 in this age group who choose to be screened should recognize that there is strong evidence that the ratio of harm to benefit increases with age and that the likelihood of overdiagnosis is extremely high particularly among men with low-risk disease. In order to identify the older man more likely to benefit from treatment if screening takes place, the Panel recommends two approaches: 1) increasing the prostate biopsy threshold (e.g., 10ng/ml) and 2) discontinuation of PSA screening among men with a PSA below 3ng/ml.