1. Guidelines for Screening
 

Risk Factors

 

Normal-risk men:

    No family history of prostate cancer

    No history of prior screening

    Not African-American

 

High-risk men:

    Family history of prostate cancer (father, brother, son)

    African-American men

    Presence of genetic mutations that predispose to prostate cancer (e.g., BRCA2)

 

Screening guidelines for normal-risk men:

 

Discuss annual PSA screening to normal risk men age 55-69 after discussion of the benefits and harms

Prostate specific antigen (PSA) measured annually
Digital rectal examination (DRE) is not a useful screening test but may help decide whether to biopsy if PSA elevated

 

DRE abnormal

Refer to urologist

 

PSA < 2.5 ng/mL & PSA velocity (rate of increase over time) < 0.35 ng/mL/year

Annual follow-up

 

PSA > 2.5 - 4.0 ng/mL or PSA velocity > 0.35 - 0.75 ng/mL/year

Refer to urologist

 

Screening recommendations for high-risk men:

 

Offer annual screening to men at high risk age 40 or older after discussion of the benefits and harms

Prostate specific antigen (PSA) annually
Digital rectal examination (DRE) annually

 

PSA >2.5 – 4 ng/mL or PSA velocity >0.35 - 0.4 ng/mL when PSA < 2.5 ng/mL

Refer to urologist for consideration of further risk stratification (cancer-specific urine or blood testing), MRI and image – guided biopsy

 

PSA > 10 ng/mL

Refer to urologist for TRUS – guided biopsy

 

If you decide you want prostate cancer screening, then request your physician to do a blood PSA test as well as a digital rectal exam if indicated.

 

2. Cancer Prevention

 

Finasteride and Dutasteride

Finasteride and dutasteride block the conversion of testosterone to dihydrotestosterone (DHT). DHT may have a role in prostate cancer development.

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In the Prostate Cancer Prevention Trial (PCPT) of healthy men age 55 or older finasteride lowered the rate of prostate cancer development compared to placebo, but those that did develop prostate cancer had more aggressive cancers. The number of  deaths from prostate cancer was the same in those taking finasteride versus placebo.

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In the Reduction by Dutasteride of Prostate Cancer Events (REDUCE) trial in men 50-75 years at increased risk for prostate cancer there were fewer cancers in those taking dutasteride compared to those taking placebo. Less aggressive prostate cancers were reduced but the number of more aggressive tumors was not.

 

Finasteride and dutasteride are associated with potential side effects that include loss of libido, erectile dysfunction and gynecomastia.

 

The FDA has added a warning that finasteride and dutasteride may increase the risk of high grade cancer, although use of these drugs is not associated with a higher risk of prostate cancer death.

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THE FOLLOWING HAVE NOT BEEN SHOWN TO BE EFFECTIVE:

Vitamin E: The SELECT trial showed that Vitamin E increased the risk (not mortality) of prostate cancer by 9%

 

POSSIBLE RISK REDUCING STRATEGIES WHICH ARE UNPROVEN:

Selenium supplements (which can have serious side effects in excess)

Diet

Multivitamins

Lycopene (conflicting data)

 

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PROSTATE CANCER SCREENING

BENEFITS AND HARMS - FREQUENTLY ASKED QUESTIONS (FAQs)

 

How is screening done?

Screening is done with a blood test for PSA level, although a digital rectal exam may be helpful.  If the PSA level is above normal, or normal but rising, it may indicate the presence of prostate cancer. 

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Are there other approaches used for interpretation of PSA tests?

Age-specific normal levels for PSA levels have also been applied for prostate cancer screening rather than 2.5 and 4.0 ng/mL levels for all men.  With age-specific evaluation, the following levels are considered normal:

Ages 40–49: < 2.5 ng/mL

Ages 50–59: < 3.5 ng/mL

Ages 60–69: < 4.5 ng/mL

Ages 70–79: < 6.5 ng/mL​

 

Who should have prostate cancer screening?

Whether or not prostate cancer screening should be done in anyone is highly controversial. The substantial likelihood of harms and the smaller likelihood of benefit have caused some groups to recommend against PSA screening.

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Men with an increased risk such as those with a strong family history of prostate cancer (father, brother, son) or who are African-American may consider screening before age 55. 

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Low risk men age 55-69 may choose to have screening once they understand the benefits and harms (see below). 

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Men with a life expectancy of less than ten years are unlikely to benefit. 

 

How often should screening be done in low-risk men who choose to be screened?

Baseline screening is started at age 50-55 years and repeated annually in the US. 

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How often should screening be done in men at increased risk?

Baseline screening may be started earlier than age 50-55 because high-risk men tend to have cancers diagnosed earlier. Testing is repeated annually, although some screening recommendations suggest that every-other year testing may be as effective as annual testing. 

 

What is the benefit of prostate cancer screening?

At least 13% reduction in death from prostate cancer, although the benefit must also consider that treatment of prostate cancer can have complications that affect quality of life.  

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What are the harms of prostate cancer screening?

In 80% of men with an increased PSA the test is a false positive and there is no cancer present. 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 needle biopsies, although use of additional biomarkers and imaging (MRI) may reduce the need for biopsy.  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. A prostate biopsy may cause pain, fever, bleeding, infection, transient urinary difficulties; with transperineal approaches to biopsy, these complications are uncommon (<1%). ​

 

What are the harms related to treatment of screen-detected cancer?

False positive PSA elevation that is not due to cancer, may result in a biopsy which can be painful. 

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Only 50-77% of men with PSA-detected prostate cancer in the United States have early treatment with surgery, radiation, or male hormone (androgen) deprivation therapy. Increasing proportions of men diagnosed with prostate cancer are now being managed with active surveillance rather than immediate treatment.

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·    Surgery:

Up to 1 in 1500 men will die within 1 month of prostate cancer surgery using modern minimally invasive techniques and between 10 and 70 men in a thousand will have serious surgical complications. Long-term adverse effects include erectile dysfunction which is more common after surgery than radiation therapy. Bowel problems can rarely occur. ​

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·    Radiation Therapy:

Bowel problems occur more frequently with radiation therapy than surgery.  Urinary bother (frequency, urgency) can be more frequent after radiation therapy.

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·    Surgery or Radiation Therapy:

Urinary incontinence occurs more frequently after surgery or radioactive seed treatment (brachytherapy). Symptoms of urinary obstruction are reduced by surgery, initially increased but decreased over time with radiation therapy and markedly increase initially and remain increased after brachytherapy. Erectile dysfunction occurs in at least 200 to 300 of 1000 men treated with these therapies. 

 

​Androgen Deprivation Therapy:

This treatment is sometimes used as primary therapy for early-stage prostate cancer, particularly in older men, although it has not been approved for this use by the U.S. Food and Drug Administration (FDA) and it has not been shown to improve survival. Adequate evidence shows that the complications include erectile dysfunction (in approximately 400 of 1000 men treated), as well as male breast enlargement (gynecomastia) and bone thinning (osteoporosis) and hot flashes as well as possible cardiovascular risk.​

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Over-Diagnosis:

There is convincing evidence that PSA-based screening lead to substantial over-diagnosis of prostate tumors. The amount of over-diagnosis of prostate cancer is of important concern. because a man with cancer that would not cause symptoms for the remainder of his life cannot benefit from screening or treatment.  This risk has been limited with the widespread adoption of active surveillance, avoiding initial treatment, for men with low-risk (Gleason Grade Group I) prostate cancer. 

 

Doctors and patients usually elect to treat most cases of screen-detected cancer, but use of risk stratification, as well as AI-imaging based evaluation of cancer risk improves our ability to identify tumors most likely to lead to symptoms or death. There is convincing evidence that PSA-based screening for prostate cancer has resulted in considerable overtreatment (treatment of cancers that would not otherwise grow) and its associated harms. The decision as to whether to undergo prostate cancer screening should only be made after review of the harms and benefits. The benefits may be greater in men at increased risk of prostate cancer and/or higher-risk cancers. 

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​Strang Cancer Prevention Institute has developed and updates guidelines for cancer screening and best practices for cancer prevention using guidelines of the National Cancer Institute (NCI), the National Consortium of Cancer Centers Network (NCCCN) and the American Cancer Society (ACS). Strang is synonymous with cancer screening and prevention. Strang was the first medical facility to introduce the Pap test into clinical practice which has saved millions of women's lives worldwide. Strang was opened by first lady Eleanor Roosevelt in 1933.

 

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