Screening

Screening for prostate cancer is controversial due to concerns regarding overdetection and overtreatment.[124][125]

Large randomised trials of prostate-specific antigen (PSA) based screening have reported mixed results.[126][127]​​​[128][129][130]​​​[131][132][133]​​​ Systematic reviews and meta-analyses suggest that PSA-based screening may modestly reduce prostate cancer-specific mortality, but not overall mortality.[124][134]​ Potential benefits of screening must be weighed against risk of overdiagnosis, complications arising from biopsy and ensuing treatment, and overtreatment.

Targeted screening strategies (e.g., risk-adapted screening starting at age 45-50 years) and strategies using other biomarkers, risk calculators, and prebiopsy MRI may help to reduce overdiagnosis.[26]​​[135][136]​​​[137][138]

PSA screening recommendations

In the US, shared decision-making prior to PSA screening is recommended for selected patients.[52][55]​​​​​​[56] Discussions about screening should start at a younger age in men at higher risk of prostate cancer (e.g., those with germline mutations, a strong family history of prostate cancer, or of black African descent).[26][139]

The American Cancer Society recommends that:[55]

  • Men age 50 years who are at average risk of prostate cancer and have a life expectancy of at least 10 years have a well-informed prostate cancer screening discussion with their physicians.

  • African-American men and men with a family history of prostate cancer (first-degree relative diagnosed <65 years) should begin discussing screening at the age of 45 years.

  • Men at very high risk (more than one first-degree relative at a young age) should begin discussing screening at the age of 40 years.

The US Preventive Services Task Force (USPSTF) recommends that:[56]

  • Clinicians discuss the potential benefits and harms of periodic PSA-based prostate cancer screening with men aged 55 to 69 years; the decision on whether to screen for prostate cancer should be individualised.

  • Patients and clinicians should take into consideration family history, race/ethnicity, comorbid medical conditions, patient values about the benefits and harms of screening and treatment-specific outcomes, and other health needs when making a decision on screening.

The American Urological Association and Society of Urologic Oncology recommend offering:[52]​​

  • A baseline screening test at ages 45-50 years in men at average risk of developing prostate cancer.

  • PSA screening starting at ages 40-45 years for men at increased risk of developing prostate cancer (e.g., black ancestry, germline mutations, strong family history of prostate cancer).

  • Regular prostate cancer screening every 2-4 years for men ages 50-69 years, although re-screening intervals may be personalised.

The National Comprehensive Cancer Network (NCCN) recommends:[26][36]​​​

  • Annual PSA screening from age 40 years for men with a BRCA2 germline mutation, and

  • Consideration of annual screening from age 40 years for men with germline mutations in other cancer susceptibility genes

In the UK, an informed choice programme exists for healthy men aged 50 years. The Prostate Cancer Risk Management Programme provides primary care practitioners with information to counsel asymptomatic men aged 50 years and over who ask about prostate specific antigen (PSA) testing for prostate cancer.[140]

Genetic risk assessment

A careful personal and family history may identify patients at increased risk of prostate cancer who should be offered genetic risk assessment (including counselling and genetic testing). Genetic risk assessment may inform shared decision-making about when to start regular prostate cancer screening.[26]

Criteria for genetic risk assessment may include:[3][26]​​​​

  • First- or second-degree relative with metastatic prostate cancer; ovarian cancer; breast cancer (male diagnosed at any age or female diagnosed at aged <45 years); colorectal or endometrial cancer diagnosed at <50 years; or pancreatic cancer

  • Two or more first- or second-degree relatives with breast, prostate, colorectal, or endometrial cancer at any age

  • Personal history of breast cancer

  • Known or suspected family or personal history of a cancer susceptibility gene mutation (e.g., BRCA1, BRCA2, ATM, CHEK2, PALB2, RAD51D, HOXB13, MLH1, MSH2, MSH6, PMS2, EPCAM, and TP53)

  • Ashkenazi Jewish ancestry

Genetic testing for a specific pathogenic variant can be carried out, if known; germline multigene panel testing is recommended if the variant is unknown.[141] 

If germline testing is positive, discussions about regular PSA screening may be started and a baseline PSA test offered with consideration of digital rectal examination.[26] Timely cascade testing (counselling and testing of blood relatives of individuals identified with a specific genetic mutation) should be offered.[3]​​​

If germline mutation testing is negative but family history is concerning, shared decision-making about when to start PSA screening is recommended.[26]

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