Uspstf Prostate Cancer Screening Guidelines

Ct Scanning Mri And Bone Scanning

Men with PSA levels above 10 ng/mL, high-grade histology , or physical findings that suggest stage T3 disease should probably undergo a staging computed tomography scan and bone scan. CT scanning is the one modality with evidence-based guidelines. The CT scan can be used to evaluate extension into the bladder and lymph nodes to help stage the patient’s cancer or to consider lymph node sampling prior to treatment.

According to the National Comprehensive Cancer Network , technetium-99m-methyl diphosphonate bone scan is indicated in the initial evaluation of patients at high risk for skeletal metastases, as indicated by any of the following :

• T1 disease, PSA 20
• Symptoms suggestive of osseous metastasis

The NCCN recommends pelvic CT or magnetic resonance imaging in patients with any of the following:

• T1-T2 disease and nomogram-indicated probability of lymph node involvement > 10%

Conventional endorectal MRI is helpful for localizing cancer within the prostate and seminal vesicles and for local staging. Dynamic, contrast-enhanced MRI and MR spectroscopic imaging are complementary in local staging, but their use is currently limited to a research setting.

• Detection of large and poorly differentiated tumors
• T staging: Detection of extracapsular extension, with high negative predictive values in low-risk men
• N staging: MpMRI is equivalent to CT scan
• M staging: MpMRI outperforms bone scan and targeted x-rays for M staging, with 98-100% sensitivity and specificity

Screening For Prostate Cancer In African American Men

Burden

In the United States, African American men are more likely to develop prostate cancer than white men . African American men are also more than twice as likely as white men to die of prostate cancer .1 The higher death rate is attributable in part to an earlier age at cancer onset, more advanced cancer stage at diagnosis, and higher rates of more aggressive cancer . These differences in death from prostate cancer may also reflect that African American men have lower rates of receiving high-quality care.

Available Evidence

The USPSTF searched for evidence about the potential benefits and harms of PSA-based screening for prostate cancer in African American men.

Potential Benefits

The PLCO trial enrolled 4% African American men, which is not enough to determine whether the overall trial results differed for African American men.17 The ERSPC trial did not record or report any race-specific subgroup information. The low proportion of persons of African descent in European countries during the study period makes it likely that these groups were not well represented.

Potential Harms

An analysis from the PLCO trial found that African American men were significantly more likely to have major infections after prostate biopsy than white men .13 Evidence is insufficient to compare the risk of false-positive results, potential for overdiagnosis, and magnitude of harms from prostate cancer treatment in African American vs other men.

Advising African American Men

Response To Public Comment

A draft version of this recommendation statement was posted for public comment on the USPSTF website from April 11 to May 8, 2017. A number of comments suggested that because men are now living longer, they should be screened beyond 70 years of age. However, the USPSTF considered other evidence in addition to data on life expectancy when recommending against screening in men older than 70 years, including results from large screening trials that did not report a mortality benefit for men older than 70 years and evidence on the increased likelihood of harm from screening, diagnostic evaluation, treatment, overdiagnosis, and overtreatment. Several comments requested a recommendation for younger men and for baseline PSA-based screening in men 40 years and older or 50 years and older. The USPSTF found inadequate evidence that screening younger men or performing baseline PSA-based screening provides benefit.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Authors followed the policy regarding conflicts of interest described at . All members of the USPSTF receive travel reimbursement and an honorarium for participating in USPSTF meetings.

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Harms Of Detection And Early Treatment

Harms Related to Screening and Diagnostic Procedures

Convincing evidence demonstrates that the PSA test often produces false-positive results .4 There is adequate evidence that false-positive PSA test results are associated with negative psychological effects, including persistent worry about prostate cancer. Men who have a false-positive test result are more likely to have additional testing, including 1 or more biopsies, in the following year than those who have a negative test result.5 Over 10 years, approximately 15% to 20% of men will have a PSA test result that triggers a biopsy, depending on the PSA threshold and testing interval used.4 New evidence from a randomized trial of treatment of screen-detected cancer indicates that roughly one third of men who have prostate biopsy experience pain, fever, bleeding, infection, transient urinary difficulties, or other issues requiring clinician follow-up that the men consider a “moderate or major problem” approximately 1% require hospitalization.6

The USPSTF considered the magnitude of these harms associated with screening and diagnostic procedures to be at least small.

Harms Related to Treatment of Screen-Detected Cancer

The USPSTF considered the magnitude of these treatment-associated harms to be at least moderate.

Accuracy Of Screening Tests

The 2002 review noted inherent problems with the use of needle biopsy results as a reference standard to assess the accuracy of prostate cancer screening tests. Biopsy detection rates vary according to the number of biopsies performed during a single procedure: The more biopsies performed, the more cancer cases detected. More cancer cases detected with a “saturation” biopsy procedure tend to increase the apparent specificity of an elevated PSA level however, many additional cancer cases detected this way are likely to be clinically unimportant. Thus, the accuracy of the PSA test for detecting clinically important prostate cancer cases cannot be determined with precision.

Longitudinal follow-up has also been used as a reference standard. A retrospective study found the sensitivity of a PSA level of 4.0 µg/L or higher to be about 91% for detecting aggressive cases of prostate cancer that developed within 2 years of screening the sensitivity was about 56% for detecting nonaggressive cancer cases within the same period. Among men who did not receive a prostate cancer diagnosis within 10 years, 9% had an initial PSA level of 4.0 µg/L or greater .11

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Healthy People 2030 Target

There is no Healthy People 2030 target related to being screened for prostate cancer. There is a target goal to increase the proportion of men who have discussed the advantages and disadvantages of the PSA test to screen for prostate cancer with their health care provider.

Healthy People 2030 is a set of goals set forth by the Department of Health and Human Services.

Note: Goals are indicated as blue line on Detailed Trend Graphs.

Percentage Of Free Psa

The measurement of bound and free PSA can help to differentiate mildly elevated PSA levels caused by cancer from elevated levels resulting from benign prostatic hyperplasia. The lower the ratio of free-to-total PSA, the higher the likelihood of cancer. For example, among men with greater than 25% free PSA, only 8% are found to have cancer at prostate biopsy.

In contrast, more than half of men with less than 10% free PSA are found to have cancer at biopsy. While cutoffs may be used, the percentage of free PSA is usually employed as an additional factor in making an informed recommendation for or against biopsy. Generally, these percentages are useful in patients who have a PSA level in the range of 4-10 ng/mL.

This information is most useful in men with very large glands or in whom 1 biopsy result has already been negative. In healthy men with a PSA level of 4-10 ng/mL, many recommend biopsy without the additional free-PSA test or consider a trial of antibiotic therapy for 4-6 weeks before repeating the PSA test.

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Risk Stratification And Staging

For patients with clinically localized prostate cancer, National Comprehensive Cancer Network guidelines define five risk categories: very low, low, intermediate, high, and very high. In contrast, the 2022 update of the American Urological Association/American Society for Radiation Oncology defines three risk categories: low, intermediate, and high the update combines the prior categories of very low risk and low-risk disease, as the recommended management for these patients is consistent. Both the NCCN and the AUA/ASTRO guidelines subdivide intermediate risk into favorable and unfavorable categories. ESMO guidlines also recommend classifying localized prostate cancer as low, intermediate, or high risk, as a guide to prognosis and therapy. See the Table below.

National Comprehensive Cancer Network Recommendations

The NCCN guidelines for prostate cancer offer treatment recommendations for CRPC based on the presence or absence of distant metastases. For the most part, these recommendations are based on high-level evidence and are supported by uniform NCCN consensus .

CRPC without distant metastasis:

• Continue ADT to maintain castrate serum levels of testosterone
• For patients with PSA doubling time (PSADT < 10 months, monitoring is preferred, but other secondary hormone therapy may be used.
• For patients with PSADT 10 months, preferred regimens are apalutamide, darolutamide, or enzalutamide.

CRPC with distant metastasis:

• Biopsy of metastatic lesion, with tumor testing for MSI-high or dMMR and homologous recombination repair gene mutations , if not previously performed consider tumor mutational burden testing
• Continue ADT to maintain castrate levels of serum testosterone
• Additional treatment options are bone antiresorptive therapy with denosumab or zoledronic acid if bone metastases are present, palliative RT for painful bone metastases, and best supportive care.
• Further treatment varies, depending on whether the tumor is an adenocarcinoma or small cell/neuroendocrine prostate cancer

Systemic therapy for mCRPC adenocarcinoma

In patients with no prior docetaxel or novel hormone therapy, category 1 treatment recommendations are as follows:

In patients who have had prior docetaxel or novel hormone therapy, treatment recommendations are as follows:

• Cisplatin/etoposide

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Benefits Of Detection And Early Treatment

The primary goal of prostate cancer screening is to reduce deaths due to prostate cancer and, thus, increase length of life. An additional important outcome would be a reduction in the development of symptomatic metastatic disease. Reduction in prostate cancer mortality was the primary outcome used in available randomized, controlled trials of prostate cancer screening. Although 1 screening trial reported on the presence of metastatic disease at the time of prostate cancer diagnosis, no study reported on the effect of screening on the development of subsequent metastatic disease, making it difficult to assess the effect of lead-time bias on the reported rates.

There is adequate evidence that the benefit of PSA screening and early treatment ranges from 0 to 1 prostate cancer deaths avoided per 1000 men screened.

Potential Harms Of Screening And Treatment

Potential Harms of Screening and Diagnosis

In addition to the ERSPC and PLCO trials, the USPSTF examined the results of a good-quality cohort study embedded within the ProtecT trial , a fair-quality cohort study conducted in the US Department of Veterans Affairs health system, as well as a report on complications of prostate biopsy from the ERSPC Rotterdam site to understand the potential harms of screening and diagnosis.3

In the large RCTs, one-fourth to one-third of men offered PSA-based screening had at least 1 positive screening test result. In the PLCO trial, 13% of men had undergone at least 1 biopsy. In the ERSPC trial, nearly 28 biopsies were performed for every 100 men randomized to screening.3 In the ProbE trial, 7.3% of men reported moderate or greater pain, 5.5% reported moderate to severe fever, and 26.6% reported troublesome hematospermia within the 35 days after biopsy.28 Complications from transrectal prostate biopsy resulted in 1.3% of men in the UK cohort, 1.6% of men in the VA cohort, and 0.5% of men in the Rotterdam cohort requiring hospitalization.30-32 In these studies, two-thirds to three-fourths of biopsies demonstrated that the PSA screening test was a false positive.3

Potential Harms of Treatment

In several studies, men older than 70 years had a significantly increased risk of medical complications and perioperative mortality after radical prostatectomy compared with younger men.3

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Prostate Cancer Screening Rates Rise Following Uspstf Guideline Update

Urology Times Journal

Rates of PSA testing for prostate cancer have increased following a 2017 decision by the US Preventive Services Task Force to no longer recommend against screening for the entire US population, according to a study from Yale Cancer Center.1

The recommendation against all screening was made by the USPSTF in 2012. The 2017 update somewhat reversed course and recommended that menaged 55 to 69 should make an individualized decision on PSA screening based on a risk-benefit discussion with their physician. For men aged 70 years, however, the USPSTF policy remained a blanket recommendation against PSA screening.

The Yale study found that the mean rate of PSA testing for men aged 40 to 89 from before to after the new USPSTF guideline was drafted and published increased from 32.5 to 36.5 tests per 100 person-years. This translates to a relative increase of 12.5%.

The findings from our study are intriguing. Increases in PSA testing were expected based on renewed support the consideration of screening from the USPSTF. These findings underscore the importance of screening guidelines from the task force and the rapid responsiveness of clinicians and patients, lead study author Michael S. Leapman, MD, stated in a recent news release.2

Using the interrupted time series analysis, investigators also found that there was a significantly increased trend of all PSA testing after April 2017 among all beneficiaries .

Reference

Metastatic Signs And Symptoms

Metastatic symptoms include weight loss and loss of appetite bone pain, with or without pathologic fracture and lower extremity pain and edema due to obstruction of venous and lymphatic tributaries by nodal metastasis. Uremic symptoms can occur from ureteral obstruction caused by local prostate growth or retroperitoneal adenopathy secondary to nodal metastasis.

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At What Age Should You Get Screened For Prostate Cancer

The following prostate cancer screening guidelines apply to men expected to live at least ten years.

Men ages 45 to 49 should have a baseline PSA test.

• If the PSA level is 3 ng / mL or higher, men should talk with their doctor about having a biopsy of the prostate.
• If the PSA level is between 1 and 3 ng / mL, men should see their doctor for another PSA test every two to four years.
• If the PSA level is less than 1 ng / mL, men should see their doctor for another PSA test between the ages of 51 and 55.

Men ages 50 to 59 should have their PSA level checked.

• If the PSA level is 3 ng / mL or higher, men should talk with their doctor about having a biopsy of the prostate.
• If the PSA level is between 1 and 3 ng / mL, men should see their doctor for another PSA test every two to four years.
• If the PSA level is less than 1 ng / mL, men should see their doctor for another PSA test at age 60.

Men ages 60 to 70 should have their PSA level checked.

• If the PSA level is 3 ng / mL or higher, men should talk with their doctor about having a biopsy of the prostate.
• If the PSA level is between 1 and 3 ng / mL, men should see their doctor for another PSA test every two to four years.
• If the PSA level is less than 1 ng / mL, no further screening is recommended.

Men ages 71 to 75 should talk with their doctor about whether to have a PSA test. This decision should be based on past PSA levels and the health of the man.

Uspstf Prostate Cancer Screening Guidelines Statement

The latest guidelines on prostate cancer screening from the United States Preventive Services Task Force indicate that doctors should not recommend routine Prostate Specific Antigen tests for men of any age. To address questions that men may have about what to do, the Prevent Cancer Foundation encourages men to talk with their doctors about the risks and benefits of prostate cancer testing. Shared decision-making between men and their doctors is the best way to resolve this important health issue.

Researchers are working to improve testing to detect prostate cancer and testing to determine whether prostate cancer is likely to lead to death from the disease. There is no question that in some cases early detection of prostate cancer followed by prompt treatment saves lives. It is also clear that some men are treated for cancers that will never cause them harm, and they must live with possible side effects and complications of treatment. Currently available tests are useful but are not 100 percent accurate. Its complicated.

To learn more about prostate cancer screening and to help you decide whether to get screened for prostate cancer, the Prevent Cancer Foundation continues to support these recommendations for the early detection of prostate cancer and recommends the American Cancer Society Testing for Prostate Cancer guide that can be viewed or downloaded here.

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Who Is The Task Force

The U.S. Preventive Services Task Force is an influential federal panel that identifies as an independent, volunteer panel of national experts in prevention and evidence-based medicine. The Task Force makes evidence-based recommendations with the stated objective to improve the health of all Americans. The USPSTFs guidelines are referenced by clinicians, patients, and payers to make informed decisions about preventative services. It is worthwhile to note that the Task Forces recommendations only apply to patients with no signs or symptoms of the specific disease or condition under evaluation, and the recommendations address only services offered in the primary care setting or services referred by a primary care clinician.