GUIDELINE SYNTHESIS
SCREENING FOR PROSTATE CANCER
Guidelines
1.
American College of
Preventive Medicine (ACPM). Screening for prostate cancer in American men. Am J Prev Med
1998 Jul;15(1):81-4 [43 references].
2.
American Urological
Association, Inc. (AUA). Prostate specific antigen: Best practice policy. Baltimore
(MD): American Urological Association, Inc., 1999. 30 p [130 references].
3.
Singapore Ministry of
Health (MOH). Prostate cancer. Singapore: Ministry of Health (Singapore);
2000 May. 49 p. (Ministry of Health Singapore clinical practice guidelines; no.
3/00). [168 references]
4.
American Cancer Society
(ACS). Recommendations from the American Cancer Society Workshop on
Early Prostate Cancer Detection, May 4-6, 2000 and ACS guideline on testing for
early prostate cancer detection: update 2001. CA Cancer J Clin 2001
Jan-Feb;51(1):39-44 [181 references].
Areas of Agreement
All
four organizations recommend against routinely screening men for prostate
cancer, primarily due to the lack of proof that screening can reduce mortality
from prostate cancer. In addition, ACPM, AUA, and ACS address the clear
potential that screening will increase treatment-related morbidity. For the
American male population, ACPM is more explicit about not recommending
population-based screening than AUA and ACS. The Singapore MOH is explicit in
their recommendations against routine prostate cancer screening in Asian males.
For men
50 years of age and older with at least a 10 year life expectancy and for men
less than 50 years of age at risk for developing prostate cancer, ACPM, AUA,
and ACS assert that men should make an informed decision regarding prostate
cancer screening with the help of their physicians. Singapore MOH suggests that
all males be considered for prostate screening who are above 40 years of age at
risk for developing prostate cancer.
The use
of transrectal ultrasound as a screening test for prostate cancer is no longer
considered by ACPM and the AUA recommends against it. ACS does not discuss this
test in their guideline, and although the Singapore MOH does not address
transrectal ultrasound as a screening test, they consider it in combination
with biopsy for diagnostic purposes.
Areas of Differences
There
are no areas of significant difference among the ACPM, AUA, Singapore MOH, and
ACS guidelines.
Abbreviations:
·
ACPM, American College
of Preventive Medicine
·
ACS, American Cancer
Society
·
AUA, American Urological
Association
·
DRE, digital rectal
examination
·
PSA, prostate specific
antigen
·
MOH, Ministry of Health
|
BENEFITS AND HARMS |
||||
|
POTENTIAL BENEFITS ASSOCIATED WITH PROSTATE CANCER SCREENING |
|
|||
|
ACPM (1998 Jul) |
Screening potentially could result in
decreased morbidity and mortality due to early detection and treatment of
prostate cancer. However, there is no direct evidence whether or not early
detection and treatment of prostate cancer reduces mortality because
randomized clinical trials to address the question have not been completed.
Because screening may be detecting cancers that would never have caused
morbidity or mortality in the host, the value of early detection remains
unclear. |
|
||
|
AUA |
PSA testing detects more tumors than does DRE
and detects them earlier. Although many of these tumors have aggressive
characteristics, some may grow slowly enough that they pose no risk to the
patient. As yet, there is no way to identify with certainty the tumor that
has no risk of spreading and potentially causing premature death or
morbidity. |
|
||
|
Singapore MOH |
While the incidence of prostate cancer is
substantially lower than that in many Western countries, it has been
increasing even after having corrected for life expectancy. The majority of
patients with prostate cancer present with locally advanced and/or metastatic
disease at the time of first diagnosis. The prognosis of advanced prostate
cancer is poor despite the most aggressive treatment. Cure is impossible for
metastatic prostate cancer. The median time to progression and median
survival is approximately 18 and 30 months respectively. Such data contrast
sharply with the results of treatment for localized disease where medial
survival has been shown to be longer than 15 years. The observed crude
survival rates are identical to the expected survival of age-matched
controls. As such, it is reasonable to strive for early diagnosis and
treatment in the hope of survival benefits. However, uncertainties of the
natural history of the disease and efficacy of treatment due to the lack of
randomised control studies still cast doubts on the potential benefits of a
screening programme. The combination of DRE and PSA enhances early
detection. Clinically significant cancers are detected by
PSA testing. PSA-based screening has induced a stage migration, but only very
preliminary indications of improved survival are available. |
|
||
|
ACS |
Prostate cancer screening may result in the
diagnosis of earlier-stage disease in younger men, which may decrease
prostate cancer mortality rates. However, no direct evidence exists to show
that prostate-specific antigen (PSA) screening decreases prostate cancer
mortality rates. |
|
||
|
POTENTIAL HARMS ASSOCIATED WITH PROSTATE CANCER SCREENING |
|
|||
|
ACPM (1998 Jul) |
Both screening and treatment can be harmful. A
positive DRE and/or PSA requiring repeat testing can lead to more invasive
diagnostic tests, such as needle biopsy, which carries a small risk of
infection, sepsis or bleeding. Radical prostatectomy and radiation therapy
can produce serious complications affecting quality of life such a urinary
incontinence, erectile dysfunction, or stricture. Little is known about the
individual psychological burden involved in prostate cancer screening and
decision-making regarding treatment. |
|
||
|
AUA |
Tradeoff associated with improving PSA
sensitivity: Both age-adjusted
PSA and PSA velocity will increase the number of cancers detected, but both
will also increase the number of men undergoing biopsy. Tradeoff associated with improving PSA
specificity: All three methods to
improve PSA specificity (age-adjusted PSA, free-to-total PSA ratio, PSA
density) will reduce the number of biopsies in men who do not have prostate
cancer but will increase the risk that some prostate cancers will be missed. Complications of confirmatory testing: Prostate biopsy by means of a transrectal, ultrasound guide,
are rarely complicated by rectal bleeding, hematuria, or prostatic infection.
After biopsy, blood in the stool or urine usually disappears in a few days.
Blood in the semen can be seen for up to several weeks after biopsy. |
|
||
|
Singapore MOH |
Not stated |
|
||
|
ACS |
Since prostate-specific antigen is
prostate-tissue specific and not prostate-cancer specific, there is no
absolute value that is applicable to all men. The range of "normal"
prostate-specific antigen levels has conventionally been considered to be
between zero and 4.0 ng/dl. A lower cut-off value of 2.5 ng/dl has been shown
to improve the early detection of organ-confined prostate cancers; however, this
also increases the number of men undergoing biopsy in whom no cancer is
detected. |
|
||
|
|
|
|
||
|
COMPARISON OF RECOMMENDATIONS FOR PROSTATE CANCER SCREENING |
|
||||
|
ACPM (1998 Jul) |
The American College of Preventive Medicine
(ACPM) recommends against routine population screening with digital rectal
examination and prostate specific antigen. Men age 50 or older with a life
expectancy of greater than 10 years should be given information about the
potential benefits and harms of screening and limits of current evidence and
should be allowed to make their own choice about screening, in consultation
with their physician, based on personal preferences. Methods and tools for
helping patients review this information are available; however, the ACPM
recommends further research be conducted in optimizing the process of patient
education and informed consent. |
|
|||
|
AUA |
Early detection of prostate cancer should be
offered to asymptomatic men 50 years of age or older with an estimated life
expectancy of more than 10 years. It is reasonable to offer testing at an
earlier age to men with defined risk factors, including men with a
first-degree relative who has prostate cancer and African American men. Decisions regarding early detection of
prostate cancer should be individualized and benefits and consequences should
be discussed with the patient before PSA testing occurs. Ideally, physicians should consider a number
of factors including patient age and comorbidity as well as preferences for
the relevant potential outcomes. Some organizations have even recommended
that informed consent should be obtained prior to PSA testing. PSA testing detects more tumors than does DRE,
and it detects them earlier. However, the most sensitive method for early
detection of prostate cancer uses both DRE and PSA. Both tests should be
employed in a program of early prostate cancer detection. Evidence from three uncontrolled studies that
allow a direct comparison of the yields of PSA and DRE suggests that
combining both tests improves the overall rate of prostate cancer detection
when compared with either test alone. The value of serial determinations of
PSA or serial DRE in patients with a normal initial examination is unknown.
There is evidence that serial PSA determinations lead to a decrease in
detection of pathologically advanced disease. Transrectal ultrasonography is not a useful
test for early prostate cancer detection; it adds little to the combination
of PSA and DRE. |
|
|||
|
Singapore MOH |
At present, population based screening is not
recommended among Asians. (Grade A,
Level Ia) All males above 40 years of age with the risk
factor of having a first degree relative with prostate cancer at young age
(younger than 60 years) may be screened. (Good Practice Point) Prostate specific antigen The appropriate threshold prostate specific
antigen level for the detection of cancer of the prostate is 4.0 ng/mL. (Grade B, Level IIb) Clinically significant cancers are detected by
testing. (Grade B, Level IIa) Prostate specific antigen-based screening has
induced a stage migration but only very preliminary indications of improved
survival are available. (Grade C,
Level IV) The ratio of free to total prostate specific
antigen levels is recommended as the sensitivity and specificity of levels at
2 to 10 ng/ ml for detecting cancer of the prostate is higher. (Grade B, Level IIa) However, the
optimal cut-off level is still being investigated. Digital rectal examination Digital rectal examination is recommended as
the combination of digital rectal examination and prostate specific antigen
test enhances early prostate cancer detection. (Grade B, Level IIa) |
|
|||
|
ACS |
The American Cancer Society (ACS) recommends
that both 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. Specifically, prior to
testing, men should have an opportunity to learn about the benefits and
limitations of testing for early prostate cancer detection and treatment. High-risk groups include men of African
descent (specifically, sub-Saharan African descent) and men with a
first-degree relative diagnosed at a young age. Risk increases with the
number of first-degree relatives affected by prostate cancer. |
|
|||
|
COMPARISON OF SCOPE AND CONTENT |
|
|
ACPM |
Objective: Interventions and Practices Considered:
Target Population: |
|
AUA |
Objective: Interventions and Practices Considered:
Target Population:
|
|
Singapore MOH |
Objective: Interventions and Practices Considered:
Target Population: |
|
ACS |
Objectives: To offer recommendations to health care
professionals and the public for informed decision-making related to early
detection of prostate cancer Interventions and Practices Considered:
Target Population:
|
GUIDELINE CONTENT COMPARISON
The
American College of Preventive Medicine (ACPM), the American Urological Association
(AUA), the Singapore Ministry of Health (MOH), and the American Cancer Society
(ACS) present recommendations for screening men for prostate cancer and provide
explicit reasoning behind their judgments.
The
guideline from the Singapore MOH provides recommendations for diagnosis,
treatment, and management of prostate cancer in addition to the recommendations
for screening for the disease. The focus of the AUA guideline is PSA and
recommendations are provided for the use of this test in screening, pretreatment
staging and post-treatment management of men with prostate cancer.
The
Singapore MOH guideline targets Asian men whereas the ACPM, AUA, and ACS
guidelines target American men.
This
Synthesis was prepared by NGC on December 28, 1998 and revised to include
additional guideline developers on April 18, 2000. It was reviewed by the
guideline developers as of June 27, 2000. Updated recommendations issued by the
American Cancer Society (ACS) were incorporated into this synthesis by NGC on
April 20, 2001 and were reviewed by the guideline developer as of August 28,
2001. This Synthesis was most recently updated on March 15, 2002 to incorporate
Singapore MOH guidelines. Recommendations from USPSTF and CTFPHC were also
removed from this Synthesis following their withdrawal from the NGC Web site.
Edward E.
Rylander, M.D.
Diplomat American
Board of Family Practice.
Diplomat American
Board of Palliative Medicine.