||Screening For Prostate Cancer
Routine screening for prostate cancer with digital
rectal examinations, serum tumor markers (e.g., prostate-specific antigen),
or transrectal ultrasound is not recommended.
Burden of Suffering
Prostate cancer is the most common noncutaneous cancer in American men.
After lung cancer, it accounts for more cancer deaths in
men than any other single cancer site. Prostate cancer accounted for an estimated
244,000 new cases and 40,400 deaths in the U.S. in 1995.
Risk increases with age, beginning at age 50, and is also higher among African
American men. Because it is more common in older men, prostate cancer ranks
21st among cancers in years of potential life lost.
death rate from prostate cancer increased by over 20% between 1973 and 1991.
The lifetime risk of dying from prostate cancer is 3.4%
for American men.
The reported incidence of prostate
cancer has increased in recent years by 6% per year, a trend attributed to
increased early detection efforts.
extension beyond the capsule of the prostate rarely produces symptoms, about
one to two thirds of patients already have local extracapsular extension or
distant metastases at the time of diagnosis.
survival rates are 75% when the cancer is confined to the prostate, 55% for
those with regional extension, and 15% for those with distant metastases.
The potential morbidity associated with progression of
prostate cancer is also substantial, including urinary tract obstruction,
bone pain, and other sequelae of metastatic disease.
Accuracy of Screening Tests
screening tests for prostate cancer are the digital rectal examination (DRE),
serum tumor markers (e.g., prostate-specific antigen [PSA]), and transrectal
ultrasound (TRUS). The reference standard for these tests is pathologic confirmation
of malignant disease in tissue obtained by biopsy or surgical resection.
The sensitivity and specificity of screening tests for prostate cancer cannot
be determined with certainty, however, because biopsies are generally not
performed on patients with negative screening test results. False-negative
results are unrecognized unless biopsies are performed for other reasons (e.g.,
abnormal results on another screening test, tissue obtained from transurethral
prostatic resection). The resulting incomplete information about the number
of true- and false-negative results makes it impossible to properly calculate
sensitivity and specificity. Only the positive predictive value (PPV) --
the probability of cancer when the test is positive -- can be calculated
with any confidence.
Even the PPV is subject to uncertainty because
of the inaccuracies of the usual reference standard. Needle biopsy, the typical
reference standard used for calculating sensitivity and specificity, has limited
sensitivity. One study suggested that as many as 19% of patients with an
initially negative needle biopsy (but abnormal screening test results) had
evidence of cancer on a second biopsy.
studies vary in the extent to which the gland is sampled during needle biopsy.
Recent studies, in which larger numbers of samples are obtained from multiple
sections of the gland, provide a different reference standard than the more
limited needle biopsies performed in older studies. These methodologic problems
account for the large variation in the reported sensitivity, specificity,
and PPV of prostate cancer screening tests and the current controversy over
their true values.
DRE is the oldest screening test for prostate
cancer. Its sensitivity is limited, however, because the examining finger
can palpate only the posterior and lateral aspects of the gland. Studies
suggest that 25-35% of tumors occur in portions of the prostate not
accessible to the examining finger.
Stage A tumors, by definition, are nonpalpable. Most recent studies report
that DRE has a sensitivity of 55-68% in detecting prostate cancer in
as low as 18-22% have also been reported in studies using different
DRE also has limited specificity, producing a large proportion of false-positive
results. The reported PPV in asymptomatic men is 6-33%
appears to be somewhat higher when performed by urologists rather than by
certain serum tumor markers (e.g., PSA and prostatic acid phosphatase) provide
another means of screening for prostate cancer. In screening studies, a PSA
value greater than 4 ng/dL has a reported sensitivity of over 80% in detecting
prostate cancer in asymptomatic men,
although a sensitivity
as low as 29% has also been reported in studies using different screening
Prostatic acid phosphatase has a much
lower sensitivity (12-20% for Stage A and B disease) and PPV (below
5%) than PSA,
and its role in screening has largely
been replaced by PSA. PSA elevations are not specific for prostate cancer.
Benign prostatic conditions such as hypertrophy and prostatitis can produce
false-positive results; about 25% of men with benign prostatic hypertrophy
(BPH) and no malignancy have an elevated PSA level.
In most screening studies involving asymptomatic men, the reported PPV
of PSA in detecting prostate cancer is 28-35%.
many instances, however, other screening tests (e.g., DRE) are also positive.
The PPV of PSA when DRE is negative appears to be about 20%.
It is unclear whether the same PPV applies when screening is performed in
the general population. Participants in most screening studies are either
patients seen in urology clinics or volunteers recruited from the community
through advertising. Studies suggest that such volunteers have different
characteristics than the general population.
example, in one screening study, 53% of the volunteers had one or more symptoms
Since PPV is a function of the prevalence
of disease, routine PSA testing of the general population, if it had a lower
prevalence of prostate cancer than volunteers, would generate a higher proportion
of false-positive results than has been reported in the literature. A significant
difference in prevalence in the two populations has not, however, been demonstrated.
Several techniques have been proposed to enhance the specificity
and PPV of the PSA test. The serum concentration of PSA appears to be influenced
by tumor volume, and some investigators have suggested that PSA density (the
PSA concentration divided by the gland volume as measured by TRUS) may help
differentiate benign from malignant disease.
According to these studies, a
PSA density greater than 0.15 ng/mL may be more predictive of cancer. Other
studies suggest that the rate of change (PSA velocity), rather than the actual
PSA level, is a better predictor of the presence of prostate cancer. An increase
of 0.75 ng/mL or higher per year has a reported specificity of 90% and 100%
in distinguishing prostate cancer from BPH and normal glands, respectively.
PSA values tend to increase with age, and investigators
have therefore proposed age-adjusted PSA reference ranges.
Current evidence is inadequate to determine the relative
superiority of any of these measures or to prove conclusively that any is
superior to absolute values of PSA.
The most effective
method to increase the PPV of PSA screening is to combine it with other screening
tests. In a large screening study, the combination of an elevated PSA and
abnormal DRE achieved a PPV of 49%. Even with this improved accuracy, however,
combined DRE and PSA screening led to the performance of needle biopsies on
18% of the screened population,
public policy issues (see below).
A large proportion of cancers
detected by PSA screening may be latent cancers, indolent tumors that are
unlikely to produce clinical symptoms or affect survival. Autopsy studies
indicate that histologic evidence of prostate cancer is present in about 30%
of men over age 50. The reported prevalence of prostate cancer in men without
previously known prostate cancer during their lifetimes is 10-42% at
age 50-59, 17-38% at age 60-69, 25-66% at age 70-79,
and 18-100% at age 80 and older.
Recent autopsy studies have even
found evidence of carcinoma in 30% of men aged 30-49.
Although patients who undergo autopsy may not be entirely representative
of the general population, these prevalence rates, combined with census data,
suggest that millions of American men have prostate cancer.
Fewer than 40,000 men in the U.S. die each year from prostate cancer, however,
suggesting that only a subset of cancers in the population are clinically
significant. Natural history studies indicate that most prostate cancers
grow slowly over a period of many years.
men with early prostate cancer (especially older men) will die of other causes
(e.g., coronary artery disease) before their cancer becomes clinically apparent.
Because a means of distinguishing definitively between indolent and progressive
cancers is not yet available, widespread screening is likely to detect a large
proportion of cancers whose effect on future morbidity and mortality is uncertain.
Recent screening studies have suggested, however, that cancers
detected by PSA screening may be of greater clinical importance than latent
cancers found on autopsy. Studies of asymptomatic patients with nonpalpable
cancers detected through PSA screening have reported extracapsular extension,
poorly differentiated cell types, tumor volumes exceeding 3 mL, and metastases
in 31-38% of cancers that were pathologically staged.
a retrospective review of radical prostatectomies performed on patients with
nonpalpable prostate cancer detected by PSA screening, 65% had a volume greater
than 1 mL, and surgical margins were positive in 26% of cases.
In a similar series, the mean tumor volume was 7.4 mL and 30% of the tumors
had penetrated the capsule.
of PSA for clinically important cancers was examined in a recent nested case-control
study among 22,000 healthy physicians participating in a long-term clinical
Archived blood samples collected at enrollment
were compared for 366 men who were diagnosed clinically with prostate cancer
during a 10-year follow-up period and 1,098 matched controls without cancer.
PSA was elevated (>4 ng/mL) in 46% of the men who subsequently developed
prostate cancer and 9% of the control group (i.e., sensitivity 46%, specificity
of 91%). For cancers diagnosed within the first 4 years of follow-up, the
sensitivity of PSA was 87% for aggressive cancers but only 53% for nonaggressive
cancers (i.e., small, well-differentiated tumors), suggesting that PSA is
more sensitive for clinically important disease. Given the low incidence
of aggressive prostate cancer in this study (1% over 10 years), the reported
specificity of 91% would generate a PPV (10-15%) that is lower than
that reported from studies using routine biopsies (28-35%).
Furthermore, this study could not address the central question of whether
PSA would have identified aggressive cancers at a potentially curable stage.
TRUS is a third means of screening for prostate cancer, but its
performance characteristics limit its usefulness as a screening test. In
most studies, TRUS has a reported sensitivity of 57-68% in detecting
prostate cancer in asymptomatic men.
Because TRUS cannot distinguish between benign and malignant nodules, its
PPV is lower than PSA. Although a PPV as high as 31% has been reported for
its reported PPV when other screening tests
are normal is only 5-9%.
Even when cancers are detected, the size of tumors is often underestimated
by TRUS. The discomfort and cost of the procedure further limit its role
of Early Detection
There is currently no evidence that screening
for prostate cancer results in reduced morbidity or mortality, in part because
few studies have prospectively examined the health outcomes of screening.
A case-control study found little evidence that DRE screening prevents metastatic
disease; the relative risk of metastatic prostate cancer for men with one
or more screening DREs compared with men with none was 0.9 (95% confidence
A cohort study also reported
little benefit from DRE screening,
but its methodologic
design has been criticized. Randomized controlled trials of DRE and PSA screening,
which are expected to provide more meaningful evidence than is currently available,
are currently under way in the U.S. and Europe.
The results of these studies, however, will not be available for over a decade.
Therefore, recommendations for the next 10 years will depend on indirect
evidence for or against effectiveness.
Indirect evidence that
early detection of prostate cancer improves outcome is limited. Survival
appears to be longer for persons with early-stage disease; 5-year survival
is 87% for Stage A (nonpalpable) tumors, 81% for Stage B (palpable, organ-confined
cancer), 64% for Stage C (local extracapsular penetration), and 30% for Stage
Due to recent screening efforts,
prostate cancer is now increasingly diagnosed at a less advanced stage. As
with survival advantages observed with other cancers, however, it is not known
to what extent lead-time and length biases account for differences in observed
survival rates (see Chapter ii). The
frequently indolent nature of prostate cancer makes length bias a particular
problem in interpreting stage-specific survival data. Successful treatment
of indolent tumors may give a false impression that "cure" was due to treatment.
Prostate cancers detected through screening are more likely to be organ-confined
than cancers detected by other means.
of radical prostatectomy often argue that such cancers are potentially curable
by removing the gland. As already noted, however, current evidence is inadequate
to determine with certainty whether these organ-confined tumors are destined
to progress or affect longevity; thus the need for treatment is often unclear.
Even if the need for treatment is accepted, the effectiveness
of available treatments is unproven. Stage C and Stage D disease are often
incurable, and the efficacy of treatment for Stage B prostate cancer is uncertain.
Currently available evidence about the effectiveness of radical prostatectomy,
radiation therapy, and hormonal treatment derives largely from case-series
reports without internal controls, usually involving carefully selected patients
and surrogate outcome measures for monitoring progression (e.g., PSA levels).
Although men treated for organ-confined
prostate cancer have a normal life expectancy, it is not clear how much their
prognosis owes to treatment. The only randomized controlled trial of prostate
cancer treatment, which compared radical prostatectomy with expectant management,
reported no difference in cumulative survival rates over 15 years, but the
study was conducted in the 1970s and suffered from several design flaws.
Randomized controlled trials
to evaluate the effectiveness of current therapies for early disease are being
launched in the U.S. and Europe, but results are not expected for 10-15
observational studies suggest that survival for early-stage prostate cancer
may be good even without treatment. A Swedish population-based cohort study
of men with early-stage, initially untreated prostate cancer found that, after
12.5 years, 10% had died of prostate cancer and 56% had died of other causes.
The 10-year disease-specific survival rate (adjusted for deaths from other
causes) for the study population was 85%. Cancer-related morbidity was significant,
however. Over one third of the cancers progressed through regional extension,
and 17% metastasized. The patient's age and the tumor stage did not significantly
influence survival rates, but tumor grade (degree of differentiation) did
affect survival; the 5-year survival rate was only 29% for poorly differentiated
Critics of the study have argued that the high survival rates were due to
the relatively large proportion of older men and of tumors detected incidentally
during transurethral prostatic resection, and that Swedish data are not generalizable
to the U.S.
have reported similar results; in one series of selected men with well- and
moderately differentiated cancer and extracapsular (nonmetastatic) extension,
5- and 9-year survival rates were 88% and 70%, respectively, without treatment.
Reported 10-year disease-specific survival for expectant
management of palpable but clinically localized prostate cancer is 84-96%.
it is unclear whether reported survival rates in these studies, in which many
cancers were detected without screening, are generalizable to screen-detected
Reviewers have attempted to compare the efficacy of treatment
and watchful waiting by pooling the results of uncontrolled studies. An analysis
of six studies concluded that conservative management of clinically localized
prostate cancer (delayed hormone therapy but no surgical or radiation therapy)
was associated with a 10-year disease-specific survival rate of 87% for men
with well- or moderately differentiated tumors and 34% for poorly differentiated
The assumptions used in the model are not
universally accepted, however.
A structured literature review concluded that the median annual rates of
metastatic disease and prostate cancer mortality were 1.7% and 0.9%, respectively,
This study was criticized for
including a large proportion of patients with well-differentiated tumors and
those receiving early androgen deprivation therapy.
Another review concluded that the annual rates for metastasis and mortality
were higher (2.5% and 1.7%, respectively), but the review was limited to patients
with palpable clinically localized cancers and excluded studies of cancers
found incidentally at prostatectomy. In this population, disease-specific
survival was estimated to be 83% for deferred treatment, 93% for radical prostatectomy,
and 74% for external radiation therapy.
effectiveness of treatment when compared with watchful waiting remains uncertain.
Uncertainties about the effectiveness of treatment are important
because of its potentially serious complications. Needle biopsy, the diagnostic
procedure performed on about 20% of men screened with DRE and PSA,
is generally safe but results in infection in 0.3-5%
of patients, septicemia in 0.6% of patients, and significant bleeding in 0.1%
The potential adverse effects of radical prostatectomy
are more substantial. Although urologists at specialized centers report operative
mortality rates of 0.2-0.3%,
published rates in clinical studies and national databases range between 0.7%
An examination of Medicare claims
files estimated that the 30-day mortality rate was 0.5%.
The reported incidence of impotence varies between 20% and 85%,
depending on definitions for impotence
and whether bilateral nerve-sparing techniques are used. Other complications
of prostatectomy include incontinence (2-27%), urethral stricture (10-18%),
thromboembolism (10%), and permanent rectal injuries (3%).
A study of Medicare patients
who underwent radical prostatectomy in the late 1980s reported a 30-day operative
mortality rate of 1% and a 4-5% incidence of perioperative cardiopulmonary
complications. Over 30% wore pads to control wetting, 6% underwent corrective
surgery for incontinence, and 2% required the use of an indwelling catheter.
Over 60% reported partial erections and 15% underwent treatment for sexual
dysfunction; 20% had dilatations or surgical procedure for strictures.
Studies of generally healthy and younger patients who have
undergone radical prostatectomy in recent years have noted considerably fewer
Complications of radiation
therapy include death (about 0.2-0.5%), acute gastrointestinal and genitourinary
complications (8-43%), chronic complications requiring surgery or prolonged
hospitalization (2%), impotence (40-67%), urethral stricture (3-8%),
and incontinence (1-2%).
conformal radiotherapy, a recently introduced technique for more precise,
high-dose treatment, is reported to produce acute and chronic gastrointestinal
or genitourinary complications in 55-76% and 11-12% of patients,
Complication rates in studies of radiation
therapy cannot be compared with confidence to reported complication rates
for surgery because of differences in study designs and patient populations.
Recent decision analyses have combined current estimates of the
benefits and harms to predict whether early treatment improves survival.
A frequently cited decision analysis for men aged 60-75 concluded that,
in most cases of clinically localized prostate cancer, neither surgery nor
radiation therapy significantly improved life expectancy.
According to the model, treatment generally results in less than 1 year of
improvement in quality-adjusted survival. In men over age 70, the analysis
suggested that treatment was more harmful than watchful waiting. The study
has been criticized because the subjects consisted largely of older men with
low-volume, low-grade tumors and because the probability estimates used in
the model may be incorrect.
Defenders of the study note that the data were adjusted for age and tumor
grade (but not stage). Retrospective quality-of-life analyses have reported
similar findings, noting that men who have undergone radical prostatectomy
or radiation therapy for localized prostate cancer generally report lower
quality of life due to impaired sexual, urinary, and bowel function than untreated
men, even after controlling for the sexual and urinary dysfunction that is
common in this age group.
analyses have examined whether screening itself improves survival. Although
older analyses suggested a modest benefit from screening,
more recent models have reached more pessimistic conclusions
when quality-of-life adjustments are incorporated. One analysis concluded
that screening and treatment result in an average loss of 3.5 quality-adjusted
months of life.
Another decision analysis concluded
that one-time screening of men aged 50-70 with either DRE or PSA would
increase life expectancy by 0-0.2 days and 0.6-1.6 days, respectively,
but quality-adjusted life would be decreased by 1.8-7.1 days and 2.1-9.5
days, respectively, per patient screened.
and calculations used in this model have also been criticized.
A recent analysis of annual screening after age 50 concluded that screening
would result in an average loss of 0.7 quality-adjusted life-years per patient
Recommendations of Other Groups
The American Cancer Society
recommends an annual
DRE for both prostate and colorectal
cancer, beginning at age 40. It recommends that the annual examination of
men age 50 and older should include a serum PSA measurement and that PSA screening
should begin at age 40 for African American men and those with a family history
of prostate cancer.
Similar recommendations have
been issued by the American Urological Association
and the American College of Radiology.
the Food and Drug Administration expanded the licensure for the PSA test to
The Canadian Task Force on the
Periodic Health Examination (CTF) recommended against the routine use of PSA
or TRUS as part of the periodic health examination; while recognizing the
limitations of DRE, they concluded that the evidence was not sufficient to
recommend that physicians discontinue use of DRE in men aged 50-70.
A 1995 report by the Office of Technology Assessment concluded
that research to date had not determined whether or not systematic early screening
for prostate cancer with PSA or DRE would save lives, and that the choice
to have screening or forego it would depend on patient values.
The recommendations of the American College of Physicians and American Academy
of Family Physicians are currently under review. In 1992, the American Urological
Association concluded that the value of TRUS as an independent screening procedure
has not been established and should be reserved for patients with an abnormal
DRE or PSA.
In summary, prostate cancer is a serious public
health problem in the United States, accounting for 35,000-40,000 deaths
each year and substantial morbidity from disease progression and metastatic
complications. Autopsy studies indicate, however, that these cases arise
from a much larger population of latent prostate cancers that are present
in over nine million American men. Although screening tests such as PSA have
adequate sensitivity to detect clinically important cancers at an early stage,
they are also likely to detect a large number of cancers of uncertain clinical
significance. The natural history of prostate cancer is currently too poorly
understood to determine with certainty which cancers are destined to produce
clinical symptoms or affect survival, which cancers will grow aggressively,
and which will remain latent. Prostate cancer has a complex biology with
many unanswered questions about heterogeneity, tumor-host interactions, and
More fundamentally, there is no evidence
to determine whether or not early detection and treatment improve survival.
For men with well- and moderately differentiated disease, treatment appears
to offer little benefit over expectant management, whereas the most aggressive
tumors may have spread beyond the prostate by the time they are detected by
screening. Observed survival advantages for men with early-stage disease
may be due to length bias and other statistical artifacts rather than an actual
improvement in clinical outcome. Although it is possible that treatment is
beneficial for an unknown proportion of men with early prostate cancer, definitive
evidence regarding effectiveness will not be available for over a decade,
when ongoing randomized controlled trials are completed. In the interim years,
during which thousands of deaths from prostate cancer are predicted, screening
might be justified for its potential benefit were it not for its potential
harms. Widespread screening will subject many men to anxiety from abnormal
test results and the discomfort of prostate biopsies; aggressive treatment
for screen-detected cancers will expose thousands of men to the risks of incontinence,
impotence, death, and other sequelae without clear evidence of benefit. Decision-analysis
models suggest that the negative impact of these complications on quality
of life may outweigh the potential benefits of treatment, but the designs
and assumptions of these models are controversial. The absence of proof that
screening can reduce mortality from prostate cancer, together with the clear
potential that screening will increase treatment-related morbidity, argues
against a policy of routine screening in asymptomatic men.
economic implications of widespread prostate screening, although not a principal
argument against its appropriateness, also warrant attention. A full discussion
of the cost effectiveness of prostate screening is beyond the scope of this
chapter. Moreover, cost effectiveness cannot be properly determined without
evidence of clinical effectiveness. Nonetheless, it is clear that routine
screening of the 28 million American men over age 50,
as recommended by some groups, would be costly. Researchers have predicted
that the first year of mass screening would cost the country $12-28
might be worthwhile if the morbidity and mortality of prostate cancer could
be reduced through early detection -- given certain assumptions, prostate
cancer screening might even achieve cost-benefit ratios comparable to breast
-- but there is currently
little evidence to support these assumptions. The costs of this form of screening,
with its emphasis on older men, is likely to increase in the future with the
advancing age of the United States population; the number of American men
over age 55 is expected to nearly double in the next 30 years, from 23 million
men in 1994 to 44 million by 2020.
is some evidence that the recent increase in prostate screening may be generating
a poorly controlled expansion in the performance of radical prostatectomies,
creating an unnecessary iatrogenic morbidity in a growing population of surgical
patients. The rising incidence of prostate cancer due to increased screening
has been accompanied by a tripling in rates for radical prostatectomy in the
If early detection and treatment are effective,
they are most likely to benefit men under age 70 rather than older men. As
already noted, 10-year survival for early-stage prostate cancer approaches
90%. Thus, most men over age 70, who face a life expectancy of just over
10 years, are more likely to die of other causes than of prostate cancer.
Subjecting these men to the risks of biopsy and treatment is often unwarranted,
and many proponents of prostate screening therefore recommend against screening
after age 70. Nonetheless, studies indicate that radical prostatectomy rates
for men aged 70-79 increased 4-fold in 1984-1990, and the trend
appears to be continuing in this decade. Population-based rates for prostatectomy
in men aged 70-79, many of whom are unlikely to benefit from the procedure,
appear to be the same as in men aged 60-69.
According to an American College of Surgeons survey, one out of three men
undergoing radical prostatectomy in 1990 was age 70 or older.
The lack of evidence regarding the benefits of prostate screening and
the considerable risks of adverse effects make it important for clinicians
to inform patients who express an interest in screening about the consequences
of testing before they consent to screening. Although such counseling is
proper for all forms of screening, the need for informed consent is especially
important for prostate cancer screening because of current uncertainty about
its effectiveness and because the proper choice for an individual is highly
dependent on personal preferences. Screening is more likely to be chosen
by men with strong fears of prostate cancer and by those who can accept the
risks of incontinence, impotence, and other treatment complications. Screening
is less likely to be chosen by men who are skeptical of the risks of cancer
and the effectiveness of treatment and who have strong fears that treatment
complications will jeopardize their quality of life.
Routine screening for prostate cancer with DRE,
serum tumor markers (e.g., PSA), or TRUS is not recommended ("D" recommendation).
Patients who request screening should be given objective information about
the potential benefits and harms of early detection and treatment. Patient
education materials that review this information are available.
If screening is to be performed, the best-evaluated approach is to screen
with DRE and PSA and to limit screening to men with a life expectancy greater
than 10 years. There is currently insufficient evidence to determine the
need and optimal interval for repeat screening or whether PSA thresholds must
be adjusted for density, velocity, or age.
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