Draft Recommendation Statement
The U.S. Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific clinical preventive services for patients without related signs or symptoms.
It bases its recommendations on the evidence of both the benefits and harms of the service, and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment.
The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision making to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms.
Screening for Prostate Cancer: U.S. Preventive Services Task Force Recommendation Statement
DRAFT
Summary of Recommendation and Evidence
This recommendation applies to men in the U.S. population that do not have symptoms that are highly suspicious for prostate cancer, regardless of age, race, or family history. The Task Force did not evaluate the use of the PSA test as part of a diagnostic strategy in men with symptoms that are highly suspicious for prostate cancer. This recommendation also does not consider the use of the PSA test for surveillance after diagnosis and/or treatment of prostate cancer. Rationale
Importance
Prostate cancer is the most commonly diagnosed nonskin cancer in men in the United States, with a lifetime risk of diagnosis currently estimated at 15.9%. Most cases of prostate cancer have a good prognosis, but some are aggressive; the lifetime risk of dying from prostate cancer is 2.8%. Prostate cancer is rare before age 50 years and very few men die of prostate cancer before age 60 years. The majority of deaths due to prostate cancer occur after age 75 years (1). Detection
Contemporary recommendations for prostate cancer screening all incorporate the measurement of serum PSA levels; other methods of detection such as digital rectal examination or ultrasonography may be included. The evidence is convincing that PSA-based screening programs result in the detection of many cases of asymptomatic prostate cancer. The evidence is also convincing that the majority of men who have asymptomatic cancer detected by PSA screening have a tumor that meets histological criteria for prostate cancer, but the tumor either will not progress or is so indolent and slow-growing that it will not affect the man’s lifespan or cause adverse health effects, as he will die of another cause first. The terms “overdiagnosis” or “pseudodisease” are used to describe both of these situations. It is difficult to determine the precise magnitude of overdiagnosis associated with any screening and treatment program. The rate of overdiagnosis of prostate cancer increases as the number of men subjected to biopsy increases. The number of cancer cases that could be detected in a screened population is large; a single study in which men eligible for PSA screening underwent biopsy irrespective of PSA level detected cancer in nearly 25% of men (2). The rate of overdiagnosis will also depend upon the age at which diagnosis is made. Cancer diagnosis in older men with shorter life expectancies is much more likely to be overdiagnosis. Benefits of Detection and Early Intervention
The primary goal of prostate cancer screening is to reduce deaths due to prostate cancer, and a reduction in either prostate cancer death or overall mortality was the primary outcome addressed in all prostate cancer screening studies assessed by the Task Force. The evidence is convincing that for men aged 70 years and older, screening has no mortality benefit. For men aged 50 to 69 years, the evidence is convincing that the reduction in prostate cancer mortality 10 years after screening is small to none. Screen-detected cancer can fall into one of three categories: cancer that results in death in spite of early diagnosis and treatment, cancer for which early diagnosis and treatment improves survival, and cancer for which the outcome would be good in the absence of screening due to indolent tumors. Ninety-five percent of men with PSA-detected cancer who are followed for 12 years do not die from that cancer, even in the absence of definitive treatment (3). The possibility is very small that death from prostate cancer is less likely in men whose prostate cancer is detected by PSA screening rather than waiting for clinical detection, and the time to any potential benefit is long. No prostate cancer screening study, individually or combined with other screening studies, or study of treatment of screen-detected cancer, has demonstrated a reduction in all-cause mortality.
Summary of Recommendations and Evidence
