How Does Evidence Fit With Biological Understanding
This recommendation replaces the 2008 recommendation.38 Whereas the USPSTF previously recommended against PSA-based screening for prostate cancer in men aged 75 years and older and concluded that the evidence was insufficient to make a recommendation in younger men, the USPSTF now recommends against PSA-based screening for prostate cancer in all age groups.
The American Urological Association recommends that PSA screening, in conjunction with a digital rectal examination, should be offered to asymptomatic men aged 40 years or older who wish to be screened, if estimated life expectancy is greater than 10 years.60 It is currently updating this guideline.61 The American Cancer Society emphasizes informed decision making for prostate cancer screening: men at average risk should receive information beginning at age 50 years, and black men or men with a family history of prostate cancer should receive information at age 45 years.62 The American College of Preventive Medicine recommends that clinicians discuss the potential benefits and harms of PSA screening with men aged 50 years or older, consider their patients’ preferences, and individualize screening decisions.63 The American Academy of Family Physicians is in the process of updating its guideline, and the American College of Physicians is currently developing a guidance statement on this topic.
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.
Prostate Specific Antigen Test
A blood test called a prostate specific antigen test measures the level of PSA in the blood. PSA is a substance made by the prostate. The levels of PSA in the blood can be higher in men who have prostate cancer. The PSA level may also be elevated in other conditions that affect the prostate.
As a rule, the higher the PSA level in the blood, the more likely a prostate problem is present. But many factors, such as age and race, can affect PSA levels. Some prostate glands make more PSA than others.
PSA levels also can be affected by
- Certain medical procedures.
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Us Task Force: End Routine Prostate Cancer Screening
* Test saves fewer than 1 man per 1,000 from dying
* Hundreds harmed by treating non-threatening tumors
* Critics say less screening will cost men their lives
NEW YORK, May 21 – A task force advising the U.S. government on Monday recommended against routine use of the prostate-cancer screening test called PSA, or prostate specific antigen, for lack of a discernible health benefit.
Like a draft proposal last October, the U.S. Preventive Services Task Force gave PSA screening a D, for dont recommend in healthy men.
The reaction was fast and furious. Screening advocates warned that the recommendation will cost lives, but critics of PSA testing said thousands of men will be spared impotence and incontinence as a result of needless cancer treatment.
A D means there is moderate or high certainty that a procedure has no net benefit or that harms outweigh benefits. It is a downgrade from the panels last PSA recommendation, in 2008, which said the evidence was insufficient to assess the procedures risks and benefits, although PSA screening for men 75 and older was not recommended.
Now, however, there is convincing evidence that the number of men who avoid dying of prostate cancer because of screening after 10 to 14 years is, at best, very small, the task force said in the May 22 issue of the Annals of Internal Medicine. Doctors, therefore, should discourage it.
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Surgical procedures to remove the diseased prostate are usually necessary. Surgical procedures are not always necessary. If the disease is caused by bacterial infections, a doctor can treat the symptoms using alpha-blockers or surgery. Physical therapy, relaxation exercises, and warm baths are all recommended. A physician may also prescribe antibiotics to cure the infection. A bacterial infection can also cause a recurrence of the condition.
An enlarged prostate can be uncomfortable for both men and women. Some of the symptoms of an enlarged male reproductive organ include a weakened urine stream, urgent need to urinate, and urinary tract infections. BPH can also cause damage to the kidneys. A sudden inability to urinate can be life-threatening, as it can lead to bladder and kidney damage. Unfortunately, most men with enlarged prostrates put up with the symptoms for years before they seek treatment. However, many of the men with symptoms finally decide to go to a doctor for proper gynecological evaluation and to begin enlarged prostatic therapy.
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An enlarged prostate can also be the cause of other problems. If the enlarged prostate is causing symptoms, the best treatment would be a natural remedy. In the meantime, there are treatments for a wide range of conditions that cause a man to experience pain. A common surgical procedure involves an electric loop, laser, or electro-stimulation. The procedure is a safe and effective option for treating enlarged or symptomatic BPH.
Treatment Of Prostate Cancer
Because the efficacy of screening depends on the effectiveness of management of screen-detected lesions, studies of treatment efficacy in early-stage disease are relevant to the issue of screening. Treatment options for early-stage disease include radical prostatectomy, definitive radiation therapy, and active surveillance . Multiple series from various years and institutions have reported the outcomes of patients with localized prostate cancer who received no treatment but were followed with surveillance alone. Outcomes have also been reported for active treatments, but valid comparisons of efficacy between surgery, radiation, and watchful waiting are seldom possible because of differences in reporting and selection factors in the various reported series.
The Prostate Intervention Versus Observation Trial was the first trial conducted in the PSA screening era that directly compared radical prostatectomy with watchful waiting. From November 1994 through January 2002, 731 men aged 75 years or younger with localized prostate cancer were randomly assigned to one of the two management strategies. About 50% of the men had nonpalpable, screen-detected disease. After a median follow-up of 10 years , there was no statistically significant difference in overall or prostate-specific mortality.
References
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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.
Estimate Of Magnitude Of Net Benefit
Conclusions from decision analysis models, which are consistent with the findings of randomized trials and cohort studies, suggest that more aggressive screening strategies, particularly those that use a lower PSA threshold for biopsy than generally used in the United States, provide the greatest potential reduction in death from prostate cancer. However, these strategies are also associated with more false positives, more biopsies, and higher rates of overdiagnosis.24
Options for reducing the overdiagnosis rate include lowering the age at which to stop screening, extending the interval between screenings, and using higher PSA thresholds for biopsy. However, no strategy completely eliminates overdiagnosis. PSA-based screening for prostate cancer every 2 or 4 years instead of annually appears to provide a good trade-off between a reduction in overdiagnosis and a small reduction in mortality benefit.24
Although active surveillance may reduce exposure to the potential harms of active treatment, it may not be viewed favorably by some men who value definitive action, are concerned about repeat biopsies, or want to avoid a potential increase in metastatic cancer.
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Research Needs And Gaps
There are many areas in need of research to improve screening for and treatment of prostate cancer, including
- Comparing different screening strategies, including different screening intervals, to fully understand the effects on benefits and harms
- Developing, validating, and providing longer-term follow-up of screening and diagnostic techniques, including risk stratification tools, use of baseline PSA level as a risk factor, and use of nonâPSA-based adjunctive tests that can distinguish nonprogressive and slowly progressive cancer from cancer that is likely to become symptomatic and affect quality or length of life, to reduce overdiagnosis and overtreatment
- Screening for and treatment of prostate cancer in African American men, including understanding the potential benefits and harms of different starting ages and screening intervals and the use of active surveillance given the large disparities in prostate cancer mortality in African American men, this should be a national priority
- How to better inform men with a family history of prostate cancer about the benefits and harms of PSA-based screening for prostate cancer, including the potential differences in outcomes between men with relatives who died of prostate cancer and men with relatives diagnosed with prostate cancer who died of other causes
- How to refine active prostate cancer treatments to minimize harms
What You Need To Know About The Prostate Us Preventive Task Force Prostate Cancer Screening
A enlarged prostate can also cause blockages in the urethra. A blocked urethra can also damage the kidneys. A patient suffering from an enlargement of the prostate may have pain in his lower abdomen and genitals. If pain is present, a digital rectal examination will reveal hard areas. A doctor may prescribe surgery or perform an endoscopic procedure. If the enlarged prostate is not completely removed, it will shrink.
While the size of an enlarged prostate will influence the extent of urinary symptoms, men may experience a range of urinary symptoms. Some men have minimal or no symptoms at all. Some men will have a very enlarged prostate, whereas others will have a mild enlargement. Generally, the symptoms can stabilize over time. Some men may have an enlarged prostate but not notice it. If they have an enlarged colon, their physician can perform a TURP procedure.
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Benefits Of Early Detection And Treatment
The goal of screening for prostate cancer is to identify high-risk, localized prostate cancer that can be successfully treated, thereby preventing the morbidity and mortality associated with advanced or metastatic prostate cancer.
Adequate evidence from randomized clinical trials shows that PSA-based screening programs in men aged 55 to 69 years may prevent approximately 1.3 deaths from prostate cancer over approximately 13 years per 1000 men screened.3, 4 Screening programs may also prevent approximately 3 cases of metastatic prostate cancer per 1000 men screened.3 Current results from screening trials show no reductions in all-cause mortality from screening. There is inadequate evidence to assess whether the benefits for African American men and men with a family history of prostate cancer aged 55 to 69 years are different than the benefits for the average-risk population. There is also inadequate evidence to assess whether there are benefits to starting screening in these high-risk groups before age 55 years.
Adequate evidence from RCTs is consistent with no benefit of PSA-based screening for prostate cancer on prostate cancer mortality in men 70 years and older.
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
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Randomized Trials Of Psa Screening
The Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial
The PLCO Cancer Screening Trial is a multicenter, randomized, two-armed trial designed to evaluate the effect of screening for prostate, lung, colorectal, and ovarian cancers on disease-specific mortality. From 1993 through 2001, 76,693 men at ten U.S. study centers were randomly assigned to receive annual screening or usual care . Men in the screening group were offered annual PSA testing for 6 years and digital rectal exam for 4 years. The subjects and health care providers received the results and decided on the type of follow-up evaluation. Usual care sometimes included screening, as some organizations have recommended.
In the screening group, rates of compliance were 85% for PSA testing and 86% for DRE. Self-reported rates of screening in the control group increased from 40% in the first year to 52% in the sixth year for PSA testing and ranged from 41% to 46% for DRE.
After 7 years of follow-up, with vital status known for 98% of men, the incidence of prostate cancer per 10,000 person-years was 116 in the screening group and 95 in the control group . The incidence of death per 10,000 person-years was 2.0 in the screening group and 1.7 in the control group . The data at 10 years were 67% complete and consistent with these overall findings . Thus, after 7 to 10 years of follow-up, the rate of death from prostate cancer was very low and did not differ significantly between the two study groups.
References
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.
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Prostate Cancer Screening Recommendations Get Rolled Back By Us Task Force
Prostate cancer screenings prevent approximately 1 death per 1,000 screenings
Routine screenings are not recommended for men 70 or older
Men between the ages of 55 and 69 particularly those at high-risk for prostate cancer should talk to their physicians about the pros and cons of prostate cancer screening, according to new guidelines released Tuesday.
The guidelines, published Tuesday in the journal JAMA, come from the US Preventive Services Task Force, an independent panel of experts that makes recommendations to the American public about preventive services. They are an update to previous guidelines published in 2012 thatrecommended against routine screening due to the risks involved in additional testing and treatment.
But according to new research, prostate-specific antigen -based screening for men in the 55 to 69 age group could prevent 1.3 deaths and 3 cases of cancer metastases for every 1,000 men screened. Therefore, the task force concluded that screening does make sense for men in that age group, but that they should be aware of the potential risks associated with additional testing.
Benefits of prostate cancer screening can include identifying and treating a potentially lethal disease. Risks include the possibleside effects of further diagnostic tests and treatment such as incontinence and erectile dysfunction, as well as the psychological effects of a false diagnosis.