Prostate Cancer

Among American men, prostate cancer is the most commonly diagnosed cancer and the second leading cause of cancer death.2 Approximately 1 in 8 (12.1%) men in the US will develop prostate cancer during their lifetime.12,19 Fortunately, less than 5% will die of their cancer and the 5-year survival rate is 98%.19 Prostate cancer more frequently occurs in men older than 50 years, non-Hispanic Black men, as well as men with a family history of prostate cancer and certain pathogenic mutations (eg, BRCA1 and BRCA2 mutations, Lynch syndrome).20 For unknown reasons, prostate cancer occurs more often at a younger age in black men.20

Historically, digital rectal examinations (DREs) were commonly performed in primary care settings to screen for prostate cancer. Evidence has shown that this test has low specificity and sensitivity and is no longer recommended as an effective screening modality.20,21 Recommendations have evolved regarding prostate cancer screening (Table 4) with a shift toward primarily biomarker-based testing with prostate-specific antigen (PSA).20-22 While PSA screening is superior to DRE, PSA-based testing remains problematic. Serum PSA levels can be confounded by benign conditions such as prostatic hyperplasia and prostatitis.20 There is no agreed-upon PSA cutoff value to determine cancer from noncancer states.21 Controversy remains regarding the age at which to start screening. Both the USPSTF and the American Urologic Association recommends considering screening may occur between ages 55 to 69 years in men at average risk, while ACS recommends routine screening starting at age 50 and as early as age 40 for higher-risk men (ie, with multiple family members diagnosed with prostate cancer before age 65 years).20-22 Potential harms of prostate cancer screening include unnecessary biopsy, which carries risks of infection, bleeding, and undue anxiety.22

Given these screening limitations, the decision to engage in prostate cancer screening is rooted in a shared decision-making framework.20-22 Within the context of shared decision-making, providers take a patient-centered approach in a bidirectional flow of information to assess patient preferences and values while providing information and individualized recommendations.18 It is crucial to talk to patients regarding the benefits and harms of prostate cancer screening. 18

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Table 4. Prostate Cancer Screening Guidelines

USPSTF20 (2018)ACS21 (2010)AUA22 (2018)
• PSA for men 55-69 y using a shared decision-making approach
• No frequency recommendation
• Recommendation against DRE
• Recommendation against screening in men ≥70 y
• PSA +/- DRE every 2 years for men ≥50 y and with >10-year life expectancy using a shared decision-making approach
• Yearly testing if PSA >2.5 ng/mL
• Consider PSA every 2 y for men 55-69 y, annually if PSA >2.5 ng/mL using a shared decision-making approach
• Recommendation against screening in men ≥70 y
ACS, American Cancer Society; DRE, digital rectal examination; PSA, prostate-specific antigen; USPSTF, United States Preventative Services Task Force