In light of the new draft recommendation from the USPSTF regarding prostate cancer screening, the ICSI Preventative Services Work Group is reviewing the recommendation for this screening in the 2011 version of the ICSI Preventive Services for Adults Guideline.

ICSI's current recommendation states:

Prostate Cancer Screening (Level III)

Service
Prostate cancer screening with prostate specific antigen and digital rectal exam of the prostate could be recommended in average-risk men 50-74 years of age. Optimal screening frequency has not been determined. For men 75 years of age or older, screening is not recommended (U.S. Preventive Services Task Force, 2008).

Efficacy
While there is good evidence that prostate specific antigen screening can detect early stage prostate cancer, the evidence is mixed or inconclusive as to whether early detection improves health outcomes. There are several ongoing large randomized controlled trials of prostate cancer screening using prostate specific antigen and digital rectal exam; recently two of these trials reported major updates (Andriole, 2009; Schroder, 2009) but thus far the evidence continues to be inconclusive and contradictory. It is hoped that these and other studies, when fully completed, will allow for more definitive recommendations. Prostate specific antigen testing is more sensitive than digital rectal exam. The work group concurs with the U.S. Preventive Services Task Force, and recommends that clinicians discuss the potential harms and benefits of prostate specific antigen/digital rectal exam screening with patients younger than 75 years of age, after which the patient and provider can come to a mutually acceptable agreement on whether or not to screen (Concato, 2006; Chan, 2003; Sirovich, 2003). The U.S. Preventive Services Task Force recommends against screening in men age 75 and older (U.S. Preventive Services Task Force, 2008).

It is also important to note that, if prostate cancer screening is pursued, the optimal screening interval is not defined. The cancer detection yield declines rapidly with more frequent testing (Roobol, 2007); although many guidelines refer to annual testing, screening less often (every 2 to 4 years) may offer equal benefit.

Benefits of screening
Earlier detection of prostate cancer offers the potential of treating the disease more effectively at an earlier stage. The prostate cancer mortality rate has decreased since the prostate-specific antigen testing became available in the United States, although the magnitude of the prostate-specific antigen role in this improvement is not well defined. Distinguishing aggressive vs. non-aggressive tumors continues to be problematic. Treatment options include surgery, radiation and watchful waiting.

Harms of screening
Screening is associated with important potential harms including frequent false-positives leading to undue anxiety and unnecessary biopsies, plus potential complications of treatment (e.g., erectile dysfunction, urine incontinence) of some cancers that may not have affected the patient's health.

Shared decision making
Because of the ambiguous balance of benefits and risk for prostate screening, shared decision making offers a strategy for reaching a decision consistent with patient preferences and values. Despite disagreement in other areas, a shared decision making approach is encouraged by many organizations such as the U.S. Preventive Services Task Force, the American Cancer Society and the American Urological Society.

Men ages 50-74 should routinely be given the opportunity to actively participate in the decision whether or not to undergo prostate cancer screening, the age of initiation and the frequency of screening. This requires a structured process and tools to assure that the patient has opportunity to understand the potential benefits, harms and limitations of testing. The decision should also take into account the patient's age, risk, stratification, life expectancy, personal values, concerns and individual circumstances.

The new evidence review can be found at:
http://www.uspreventiveservicestaskforce.org/uspstf12/prostate/prostateart.htm

The ICSI Preventative Services Work Group welcomes you comments on this issue. Enter your comments here: http://www.surveymonkey.com/s/38FCJF2.