What is the most useful first line test for the diagnosis of prostate cancer?
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Diagnostic pathwayfor prostate cancerLocalisedStageI or IIStageIII or IVAdvancedAbnormalbiopsyandstagingNo cancerdiagnosisNormalbiopsyStill possible tohave a biopsy andbe diagnosed,based on clinicalsuspicionNoBiopsyBiopsyNormalPSAElevatedPSAorChoices consideredin this comparisonProstate-specificantigen (PSA)screeningNo PSAscreeningWidth of lines proportional toapproximate numbers of peopleSubsequent treatmentSurgeryRadiationActive surveillanceWith or withouthormonal therapyCan be followed byradical treatmentMen without aprevious diagnosisof prostate cancerconsidering screening ComparisonorScreeningNo screeningScreeningNo screeningUsing prostate-specific antigentesting We suggest against systematic PSA-based screening for prostate cancer. Either option isreasonable. Shared decision making is needed for men considering screening.MoredetailsStrongAll or nearly all informed people would likely want this option.Benefits outweigh harms for almost everyone.WeakMost people would likely want this option.Benefits outweigh harms for the majority, but not for everyone.WeakMost people would likely want this option.Benefits outweigh harms for the majority, but not for everyone.StrongAll or nearly all informed people would likely want this option.Benefits outweigh harms for almost everyone.Comparison of benefits and harms All evidenceWith screeningWith no screeningEvidence qualityEvents per 1000 peopleWithin 10 yearsNo important differenceThe panel found that these differences were notimportant for most patients, because theintervention effects were negligible and/or veryimprecise (such as statistically not significant) No important differenceAll cause mortalityModerateMore129128Risk of BiasSeriousImprecisionNo serious concernsIndirectnessNo serious concernsInconsistencyNo serious concernsPublication biasNo serious concernsPSA screening probably has little or noeffect on all cause mortality No important differenceProstate cancer mortalityLowMore33Risk of BiasSeriousImprecisionNo serious concernsIndirectnessNo serious concernsInconsistencySeriousPublication biasNo serious concernsPSA screening may have little or noeffect on prostate cancer mortality 7 fewerIncidence of cancer (any stage)LowMore3239Risk of BiasSeriousImprecisionBecause of inconsistencyIndirectnessNo serious concernsInconsistencySeriousPublication biasNo serious concernsPSA screening may increase thedetection of prostate cancer (any stage) 7 fewerIncidence of localized cancerLowMore1926Risk of BiasSeriousImprecisionBecause of inconsistencyIndirectnessNo serious concernsInconsistencySeriousPublication biasNo serious concernsPSA screening may increase thedetection of localized cancer (stage I or II) Incidence of advanced cancerLowMore1311No important differenceRisk of BiasSeriousImprecisionNo serious concernsIndirectnessNo serious concernsInconsistencySeriousPublication biasNo serious concernsPSA screening may have little or noeffect on the detection of advancedcancer (stage III or IV) Within 1 month FewerBiopsy-related complicationsLowMoreAmong 1000 men with PSA screening, morepresented with complications due to prostatebiopsies:Blood in semen: 94Pain: 45Fever:19Hospitalized for sepsis:1Blood in urine: 67Because of uncertainty due toestimating likelihood alongthe diagnostic pathway At any time FewerCancer treatment complicationsLowMoreAmong 1000 men with PSA screening, morepresented with complications due to cancertreatment:Erection not firm enough for intercourse: 25Urinary incontinence: 3Because of uncertainty due toestimating likelihood alongthe diagnostic pathway See patient decision aids See all outcomes Selected evidence at lower risk of biasThis section includes only data from the ERSPC trial, conducted in 162 243 participants in 9 European countriesWith screeningWith no screeningEvidence qualityEvents per 1000 peopleWithin 10 yearsNo important differenceThe panel found that these differences were notimportant for most patients, because theintervention effects were negligible and/or veryimprecise (such as statistically not significant) No important differenceModerateMore129129All cause mortalityRisk of BiasSeriousImprecisionNo serious concernsIndirectnessNo serious concernsInconsistencyNo serious concernsPublication biasNo serious concernsPSA screening probably has little or noeffect on all cause mortality 1 fewerModerateMore32Prostate cancer mortalityRisk of BiasSeriousImprecisionNo serious concernsIndirectnessNo serious concernsInconsistencyNo serious concernsPublication biasNo serious concernsPSA screening probably leads to a smallreduction in prostate cancer mortality 18 fewerModerateMore3250Incidence of cancer (any stage)Risk of BiasSeriousImprecisionNo serious concernsIndirectnessNo serious concernsInconsistencyNo serious concernsPublication biasNo serious concernsPSA screening probably increases thedetection of prostate cancer (any stage) 14 fewerModerateMore1933Incidence of localized cancerRisk of BiasSeriousImprecisionNo serious concernsIndirectnessNo serious concernsInconsistencyNo serious concernsPublication biasNo serious concernsPSA screening probably increases thedetection of localized cancer (stage I or II) 13ModerateMore3 fewer10Incidence of advanced cancerRisk of BiasSeriousImprecisionNo serious concernsIndirectnessNo serious concernsInconsistencyNo serious concernsPublication biasNo serious concernsPSA screening probably slightlydecreases the detection of advancedcancer (stage III or IV) Within 1 month LowMoreBiopsy-related complicationsFewerAmong 1000 men with PSA screening, morepresented with complications due to prostatebiopsies:Blood in semen: 94Pain: 45Fever:19Hospitalized for sepsis:1Blood in urine: 67Because of uncertainty due toestimating likelihood alongthe diagnostic pathway At any time LowMoreCancer treatment complicationsFewerAmong 1000 men with PSA screening, morepresented with complications due to cancertreatment:Erection not firm enough for intercourse: 25Urinary incontinence: 3Because of uncertainty due toestimating likelihood alongthe diagnostic pathway See patient decision aids See all outcomes Men with family history of prostate cancerFamily history defined positive if man’s father or at least one brother had been diagnosed with prostate cancerWith screeningWith no screeningEvidence qualityEvents per 1000 peopleWithin 10 yearsNo important differenceThe panel found that these differences were notimportant for most patients, because theintervention effects were negligible and/or veryimprecise (such as statistically not significant) 29 fewerIncidence of cancer (any stage)ModerateMore5079Risk of BiasSeriousImprecisionNo serious concernsIndirectnessNo serious concernsInconsistencyNo serious concernsPublication biasNo serious concernsPSA screening probably increases thedetection of prostate cancer (any stage) 19 fewer25Incidence of localized cancerModerateMore44Risk of BiasSeriousImprecisionNo serious concernsIndirectnessNo serious concernsInconsistencyNo serious concernsPublication biasNo serious concernsPSA screening probably increases thedetection of localized cancer (stage I or II) See patient decision aids See all outcomes Men of African descentWith screeningWith no screeningEvidence qualityEvents per 1000 peopleWithin 10 yearsNo important differenceThe panel found that these differences were notimportant for most patients, because theintervention effects were negligible and/or veryimprecise (such as statistically not significant) Prostate cancer mortalityModerateMore71 fewer6Risk of BiasSeriousImprecisionNo serious concernsIndirectnessNo serious concernsInconsistencyNo serious concernsPublication biasNo serious concernsPSA screening probably has little or noeffect on prostate cancer mortality 29 fewerIncidence of cancer (any stage)ModerateMore5180Risk of BiasSeriousImprecisionNo serious concernsIndirectnessNo serious concernsInconsistencyNo serious concernsPublication biasNo serious concernsPSA screening probably increases thedetection of prostate cancer (any stage) See patient decision aids See all outcomes Men with these characteristicscarry a higher incidence of prostatecancer, and could be at higher riskof dying of prostate cancer. Itremains uncertain whether theimpact of screening is similar inthese higher risk men incomparison to men at lower risk.Men at higher risksThere is considerable variabilityamong men's values andpreferences regarding prostatecancer screening. Men who place ahigh value in avoidingcomplications from biopsies andsubsequent treatment are likely todecline screening. In contrast, menwho place a higher value in even asmall reduction of prostate cancermortality may opt for screening.Higher risk patients may be morelikely to seek screening becausethey may worry more aboutprostate cancer and want to ruleout the diagnosis.Values and preferencesLUTS symptoms like these arecommon complaints in adult menthat can have a major impact onquality of life and substantialeconomic burden. The aetiology ofLUTS is multifactorial, benignprostatic enlargement, due tohyperplasia, being the major cause.Evidence to date indicates thatmen with LUTS are at no higherrisk of prostate cancer than menwithout LUTS.Lower Urinary TractSymptoms (LUTS)Key practical issuesPSA testing is done with a regular blood sampleUsually taken through rectum guided by ultrasoundTakes about 5-10 minutesAntibiotics given before procedureLocal anaesthesia or sedation given before procedureMay have to stop blood thinners before procedureScreeningIf biopsy is requiredSlow streamSensation of incomplete emptyingIncreased urinary frequencyFamily history of prostate cancerAfrican descentPoorer socio-economic groups ©BMJ Publishing Group Limited. Disclaimer: This infographic is not a validated clinical decision aid. This information is provided without any representations, conditions or warranties that it is accurate or up to date. BMJ and its licensors assume no responsibility for any aspect of treatment administered with the aid of this information. Any reliance placed on this information is strictly at the user's own risk. For the full disclaimer wording see BMJ's terms and conditions: https://www.bmj.com/company/legal-information/ Find recommendations, evidence summaries andconsultation decision aids for use in your practice
What you need to know
What is the role of prostate-specific antigen (PSA) screening in prostate cancer? An expert panel produced these recommendations based on a linked systematic review. The review was triggered by a large scale, cluster randomised trial on PSA screening in men without a previous diagnosis of prostate cancer published in 2018 (). It found no difference between one-time PSA screening and standard practice in prostate cancer mortality but found an increase in the detection of low risk prostate cancer after a median follow-up of 10 years. Box 1 Results of the CAP Randomized Clinical TrialThis cluster-randomised trial of 419 582 British men was published in March 2018. After a median follow-up of 10 years, there was no significant difference in prostate cancer-specific mortality in men receiving care by general practices randomised to a single PSA screening intervention compared with men receiving care by practices randomised to standard practice without screening. The detection of low risk prostate cancer cases was higher in the PSA screening group. Although the trial had limitations, such as low adherence to PSA testing in the intervention arm (36%) and a follow-up of only 10 years, its findings do not support the use of single PSA testing for population based screening. The Rapid Recommendations executive felt this new study—taken together with extended follow-up data from existing trials—required a new appraisal of the body of evidence for patients and clinicians. Although the results of this study suggest screening is not worthwhile, several guidelines advocate offering screening in some cases. The study was much larger than previous studies, and existing trials had published more extended follow-up results, and the BMJ Rapid Recommendations team felt these merited a new appraisal of the body of evidence. This guideline aims to promptly and transparently translate potentially practice-changing evidence to usable recommendations for clinicians and patients, based on the GRADE framework and following standards for trustworthy guidelines. The panel suggests against systematic PSA screening (weak recommendation). The panel members judged that most men will decline screening because the benefit is small and uncertain and there are clear harms. However, there is likely considerable variation in values and preferences. Men with family history of prostate cancer, African descent or of lower socioeconomic status, having higher baseline risk of prostate cancer death, may be more likely to choose PSA screening. Shared decision making is needed for men considering screening. shows all of the articles and evidence linked in this Rapid Recommendation package. The main infographic provides an overview of the absolute benefits and harms of PSA screening. The table at the end of the article shows any evidence that has emerged since the publication of this guideline. Box 2 Linked articles in this BMJ Rapid Recommendation cluster
Current practiceProstate cancer is one of the most common cancers in men and is the leading cause of cancer death in 24 countries, ranking eighth globally, sixth in high income countries, and 12th in low income countries. Prostate cancer screening is with a PSA blood test. A raised PSA level can be a sign of prostate cancer but can also occur due to a non-cancerous enlargement or inflammation of the prostate. Many men have a raised PSA level without having cancer (that is, false positive results). Conversely, a substantial number of men with a low PSA level will subsequently be diagnosed with prostate cancer (false negative results). Investigations after raised PSAIf PSA is raised, the test is usually repeated. Men with persistently elevated PSA levels typically undergo a transrectal, ultrasound-guided, core-needle biopsy of the prostate to test for prostate cancer (see main infographic). If cancer is detected in the biopsied tissue, management options include surgery, radiation therapy, hormonal treatment, active surveillance, or watchful waiting. Diagnostic imaging studies such as ultrasonography, magnetic resonance imaging (MRI), bone scan, and computed tomography, are often also performed, especially in men presenting with higher risk disease, to check for disease spread. Screening controversyFor many reasons, PSA screening remains controversial. Advocates often base their opinions on the European Randomised study of Screening for Prostate Cancer (ERSPC), which suggests that screening may reduce the long term risk of prostate cancer-specific mortality by at least 9% (relative reduction). They also note that substantial observational evidence indicates a reduction in advanced disease and reduction in prostate cancer mortality, which they attribute to the introduction of PSA screening. Opponents of PSA screening highlight the indolent natural course of prostate cancer, citing systematic reviews that reported little or no impact of PSA screening on overall and prostate cancer-specific mortality. Opponents also suggest that the harms and burden from overdiagnosis and overtreatment resulting in unnecessary prostate biopsies and impaired urinary, sexual, and bowel function as side effects of surgery or radiation therapy outweigh the uncertain and modest benefits. Current guidelines on PSA testingGuidelines vary in their recommendations on PSA testing (see ). The Canadian Task Force on Preventive Health Care recommends against PSA screening for men aged 55 to 69 years. However, the US Preventive Services Task Force recently changed its guidance to say that “the decision about whether to be screened for prostate cancer should be an individual one,” without clearly suggesting for or against screening: previously it recommended against screening in that group. National Cancer Center Network (NCCN) guidelines (which represents cancer centres in the USA) recommends initiating PSA screening at age 45 years. Guidelines from the American Urological Association (AUA) and European Association of Urology (EAU) recommend a discussion about PSA screening with patients. Table 1 Major guideline recommendations on PSA screening* View this table:
Uptake of PSA testingThe incidence of prostate cancer has dramatically increased over the last quarter century. This has been associated with widespread use of prostate specific antigen (PSA) testing detecting early stage prostate cancers. There is wide variation in the adoption of prostate cancer screening. In the UK, about 39% of men aged 45-69 years have undergone PSA testing in the past 10 years. In Sweden 23% of men aged 50-69 had a PSA test in the previous 12 months and 58% in the previous 10 years. Although the rates of screening have declined during the past decade in the US, up to half of US men aged 60-74 undergo screening each year. Also, as many as 33% of elderly US men with competing medical comorbidities at high risk of dying from other cause underwent screening, and twice as many of these men recalled discussing the potential benefits rather than harms of screening. African-Americans were less likely to have been screened than non-African US men. Overall, two thirds of men reported no past discussion with physicians about the advantages, disadvantages, or scientific uncertainty and no shared decision making about prostate cancer screening. How this recommendation was createdOur international panel included patient partners (men at risk of prostate cancer), general practitioners, general internists, urologists, epidemiologists, methodologists, and statisticians. They determined the scope of the question that the recommendation should address and what outcomes are most important to patients considering screening. No person had financial conflicts of interest; intellectual and professional conflicts were minimised and managed (see appendix 1 on bmj.com). The panel identified eight critical outcomes needed to inform the recommendations: all-cause mortality; prostate cancer mortality; incidence of prostate cancer diagnoses (all stages); incidence of localised cancer (stage I and II); incidence of advanced cancer (stage III and IV); complications from biopsies (such as bleeding, pain, infections, and hospital readmissions), complications from prostate cancer treatment (such as urinary incontinence and erectile dysfunction); and quality of life. The panel also identified three additional patient-important outcomes: false positive rates (men with elevated PSA levels who will have negative biopsy); false negative rates (men with a normal PSA result who will subsequently be diagnosed with cancer), and the anxiety and uncertainty related to concerns about having prostate cancer. The panel asked that potential subgroups effects be explored according to age, screening interval, family history, being of African descent, and being of lower socioeconomic level. They also asked for a sensitivity analysis of the effect of screening restricted to trials at lower risk of bias. To inform the recommendation, the panel members requested two systematic reviews, on the following questions:
Two parallel teams conducted these systematic reviews, which are linked to this publication. The panel met to discuss the evidence and formulate a recommendation. They followed the BMJ Rapid Recommendations procedures for creating a trustworthy recommendation, including use of the GRADE approach to interpret the evidence and create recommendations (see appendix 2 on bmj.com). The panel considered the balance of benefits, harms, and burdens of PSA screening; the quality of the evidence for each outcome; and typical and expected variations in patient values and preferences, as well as feasibility and acceptability. Recommendations can be strong or weak, for or against a course of action. The recommendations take a patient centred perspective which de-emphasises public health, societal, and health payer point of view. The evidenceThe updated systematic review on the benefits and harms of PSA screening pools data from five randomised controlled trials (with ERSPC comprising eight European countries), which enrolled a total of 721 718 men (with 419 582 included in the latest CAP trial). Main characteristics and limitations of the trialsprovides an overview of the trials’ characteristics and the patients included. All trials had methodological limitations. In the CAP trial only 36% of men randomised to the screening arm actually underwent PSA testing (that is, low adherence to screening), while about 10-15% in the non-screening arm were actually tested (that is, contamination). CAP also differed from other large scale trials in that it used one-time screening, whereas others used repeated screening with intervals varying from annual to every two years or more. Fig 2 Characteristics of patients and trials included in systematic review of the use of the prostate-specific antigen (PSA) test for prostate cancer screening.
The Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening trial conducted in the US lacked allocation concealment, and rates of PSA testing in the non-screening arm exceeded 50%, possibly as high as 80%. The European Randomised Study of Screening for Prostate Cancer (ERSPC) was conducted in eight European countries. There was possibly inadequate allocation concealment, and there are concerns that groups may have received different quality of treatment for prostate cancer (performance bias). Nevertheless, the systematic review authors judged the ERSPC trial to be the one that was probably least affected by bias. Based on a predefined sensitivity analysis, the BMJ Rapid Recommendations panel decided to appraise both the summary of the whole body of evidence as well as selected data at lower risk of bias from the ERSPC study (see main infographic). Although most studies reported mortality and cancer incidence, there was limited randomised data on complications from biopsies or subsequent prostate cancer treatment and on quality of life. The systematic review team therefore searched for available follow-up evidence from the intervention arms of included trials and follow-up publications. They used ERSPC sub-data for quality of life (that is, the Finnish arm of the study) and false positive rates. They estimated false negative rates among men with a low PSA level from a follow-up cohort study of the Prostate Cancer Prevention Trial. Complications rates from subsequent treatment modalities were obtained from the ProtecT trial embedded in the CAP trial—in which patients diagnosed with prostate cancer in the CAP screening trial were randomised to active monitoring, radical prostatectomy, or radical radiotherapy with hormones. Similarly, complication rates from biopsies were obtained from the Prostate Biopsy Effects cohort study nested within the ProtecT trial. By modelling the likelihood of elevated PSA values, biopsies, cancer diagnoses, and treatment modalities (from the NIH’s Surveillance, Epidemiology, and End Results (SEER) programme), the linked systematic review estimated the absolute number of biopsy and treatment related complications among men who underwent screening versus those who did not (see infographic and appendix 3 on bmj.com for more details). The quality of evidence assessment with GRADE considers the unique limitations in the evidence for each outcome. Evidence on men’s values and preferencesEvidence suggests that different men judge the benefits and harms of PSA testing and its consequences differently. The linked systematic review on the values and preferences of men considering PSA screening included studies that reported quantitative data on the degree of benefits (such as reduction in mortality risk) that men would require and degree of harms (such as increase in risk of incontinence) that men would be willing to accept to undergo prostate cancer screening. Five studies were identified that investigated a direct choice related to PSA screening. The studies used different methodologies and varied considerably in how their outcomes were reported. One study showed that men were willing to forego screening with a benefit of 2% on prostate cancer mortality if it increases their probability of avoiding unnecessary biopsies by 10% or avoiding unnecessary treatment by 10%. In another study, men were willing to accept between 65 and 233 per 10 000 unnecessary biopsies to avoid one per 10 000 prostate cancer deaths. These results varied with age: men in their 50s were willing to accept more unnecessary biopsies than men in their 40s or in their 60s. The review also included six studies in which men were presented with decision aids showing outcomes such as prostate cancer diagnosis and prostate cancer mortality. Willingness to undergo screening varied from 37% in a study displaying a reduction in mortality of 10 per 1000 men to 44% in a study displaying a reduction in mortality of 7 per 1000. The review found no studies that specifically investigated whether the men’s values and preferences differed among men with a family history of prostate cancer, men of African descent, or men of lower socioeconomic class. Understanding the recommendationThe recommendation against PSA screening is weak because of the small and uncertain benefits of screening on prostate cancer mortality and the large variability in men’s values and preferences. In practice, a weak recommendation means that shared decision making is important. Clinicians should support men considering screening to make a well informed decision in line with their own risk profile and individual values and preferences. Another implication of our weak recommendation is that clinicians do not need to raise the issue systematically with their patients. They could raise PSA screening or wait for the patient to raise the issue. Both approaches are reasonable. It depends on the patient’s context and competing issues in each clinical encounter. The panel believes that most informed men considering screening would decline it, although some would choose to undergo screening, accepting the diagnostic and therapeutic burden and harms that can result. Absolute benefits and harmsThe main infographic explains the recommendation and provides an overview of the absolute benefits and harms of screening at a 10 year time horizon for consistency and easier communication. However, the individual trials varied in their duration of follow-up from 10 to 20 years (), and we used the relative estimates of effect, pooled in the linked systematic review, at the longest available follow-up time. For the 10 year time horizon, we used as baseline risk in the non-screening arm of the CAP trial. It provided the most contemporary estimates of risks from a large sample of men representative of a general practice setting. Death and cancer diagnosisPSA screening may increase the detection of prostate cancer (7 more per 1000 men (95% confidence interval 1 to 15 more) at 10 years), particularly of localised cancer (7 more per 1000 men (2 to 15 more)). But the data show no difference in prostate cancer mortality. Overall confidence in these estimates across these outcomes was low because of risk of bias as well as the inconsistency of findings across studies.
Harms linked to management of prostate cancer
Quality of life
Adapting the offer for men at higher risk of prostate cancer and deathThe linked systematic review did not find a relative subgroup effect by age: the effects of screening are consistent across age strata. Age of men enrolling in the studies ranged from 45 to 80 years, with most aged 50-69 years. The panel believes the evidence thus applies to men regardless of age. However, any possible benefit of screening is likely to become negligible as life expectancy decreases due to age or comorbidities. There were no randomised data on whether screening efficacy differed in those with a family history of prostate cancer, men of African descent, or men from lower socioeconomic levels. It remains uncertain whether the relative effect of screening is similar to that in the general population. However, these factors are associated with higher incidence of prostate cancer and higher risk of prostate cancer death in observational studies, as well as in follow-up publications of the trials included in the linked review (Finnish and Swiss arms from the ERSPC trial and the PLCO trial). Using evidence from these trials, we adapted the baseline risk in our summary of findings, using the same studies at lower risk of bias (that is, ERSPC data). In these studies, family history was assessed by self reporting in a questionnaire and defined positive if a man reported that his father or at least one brother had been diagnosed with prostate cancer. For race or ethnicity, non-Hispanic black men were compared with non-Hispanic white men. Level of education was used as a proxy for socioeconomic status, and men with primary education only were defined as having a low level of education and men with secondary or tertiary education defined as having high level of education.
Values and preferencesThe panel, including the patient partners, felt that this variability in values and preferences contributes to a weak recommendation. The recommendation against screening reflects a belief that most men would value avoiding complications from biopsies and subsequent treatment because the reduction in prostate cancer and death from screening is small and uncertain. Prostate cancer will often, though not always, remain indolent. Men who place a high value on avoiding complications from biopsies and subsequent treatment are likely to decline screening. In contrast, men who place a higher value on even a small reduction of prostate cancer may opt for screening. Several panel members felt that higher risk patients—such as patients with family history of cancer or of African descent—may be more likely to seek screening because they may worry more about prostate cancer and want to rule out the diagnosis. For men considering screening, shared decision making is critical to ensure that their decision is in line with their own values and preferences. The evidence summarised in this Rapid Recommendation is available in MAGICapp as decision aids that can support shared decision making (https://app.magicapp.org/public/guideline/n32gkL). Practical issues and other considerationsoutlines the key practical issues. PSA testing can be performed on any normal blood sample, but prostate biopsies and their follow-up have important implications for daily life. Fig 3 Practical issues about use of prostate-specific antigen (PSA) testing and biopsy for prostate cancer screening
Lower urinary tract symptoms (slow urine stream, sensation of incomplete emptying, increased urinary frequency) are common complaints in adult men that can have a major impact on quality of life. Benign prostatic enlargement is the major cause. Evidence to date indicates that men with these complaints are not at increased risk of prostate cancer. For men who chose to undergo PSA testing, the optimal frequency of screening remains unknown. summarises the frequency used in the different trials, yet the accompanying systematic review did not find any significant subgroup effect of the effect of screening based on these different frequencies. Given that the ERSPC data are likely at lower risk of bias, PSA screening every four years—rather than, say, every year or only once in a lifetime—may be the optimal interval. Costs and resourcesResults from a recent cost-effectiveness study modelled for the US suggested that screening between the ages of 55 and 69 years combined with active surveillance for low risk men could only be cost-effective at a $100 000 threshold if the screening frequency remains low (every four years) and active surveillance is offered to all men with low risk prostate cancer (that is, Gleason score ≤6 and stage ≤T2a). Strategies with shorter screening intervals or in which immediate treatment is offered to all men were not cost-effective. Although the Rapid Recommendations panel focused on the patients’ priorities rather than those of society, our recommendation is compatible with these findings. Uncertainties for future researchRecent evidence suggests that incorporating MRI in the investigation of those with a positive PSA test result decreases the false positive rate, and thus the number of patients undergoing unnecessary biopsies, and may also increase the accuracy of biopsies in those who do have prostate cancer. The Rapid Recommendations panel considered addressing this issue in the guideline, but the impact of MRI on long term outcomes of prostate cancer incidence, mortality, and complications of treatment remains uncertain. Sophisticated decision modelling might shed light on this issue, but the panel decided not to conduct such an analysis because of logistic and feasibility considerations, and because the panel’s review of the evidence suggests that modelling would introduce further uncertainties regarding the impact of MRI on patient-important outcomes. Key research question to inform decision makers and future guidelines include
Updates to this articleThe final table shows evidence that has emerged since the publication of this article. As new evidence is published, a group will assess the new evidence and make a judgment on the extent it is expected to alter the recommendation. New evidence which has emerged after initial publication View this table:
Education into practice
How patients were involved in the creation of this article:Three men eligible for PSA screening were full panel members. They identified important outcomes and led the discussion on values and preferences. They fully participated in the teleconferences and email discussions on the evidence and the recommendation. They also contributed to the identification of practical issues related to the decision to undergo PSA screening, and met all authorship criteria for the present article. AcknowledgmentsWe thank Drs Tuomas Kilpeläinen and Eric Miller for providing additional information about the original studies. Footnotes
This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/. References
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