Screening for prostate cancer: the current evidence and guidelines controversy

Prostate cancer presents a global public health dilemma. While screening with prostate specific antigen (PSA) has led to more men diagnosed with prostate cancer than in previous years, the potential for negative effects from over-diagnosis and treatment cannot be ignored.

We reviewed Medline for recent articles that discuss clinical trials, evidence based recommendations and guidelines from major medical organizations in the United States and worldwide concerning prostate cancer screening.

Results from the European Randomized Screening for Prostate Cancer (ERSPC), the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, and Göteborg Swedish trials regarding prostate screening are controversial with the ERSPC and Göteborg showing a reduction in prostate cancer mortality and the PLCO trial showing no benefit. Recommendations from the American Urological Association (AUA), Japanese Urological Association (JUA), and National Comprehensive Cancer Network (NCCN) have recommended that all men obtain a baseline PSA beginning at age 40. The American Cancer Society (ACS) stratifies screening recommendations based on age and risk, but states that screening should take place only after an informed discussion between provider and patient. The United States Preventative Health Service Task Force (USPSTF) states that evidence is insufficient to assess the risks and benefits of prostate cancer screening in men younger than 75 years. Other major international health organizations offer a similar reserved approach or recommend against screening for prostate cancer. Most groups indicate that screening to determine who should undergo prostate biopsy typically includes both a serum PSA and digital rectal examination, with the latest ACS publications noting that the rectal exam is optional. A common theme from all groups is that an informed discussion with the patients is strongly recommended and that screening does increase the number of men diagnosed with non-metastatic, early disease.

Prostate cancer screening guidelines vary widely between countries and between different medical organizations within individual countries including the United States. Further, the evidence for and against prostate cancer screening remains highly controversial. Longitudinal follow up of completed screening trials is ongoing and may yield additional findings as the time course of prostate cancer outcomes can be protracted. The literature controversy suggests that no standard of care exists for prostate cancer screening today. Until there is agreement in guidelines between major professional organizations who have weighed in on this topic, patients and physicians should be encouraged to consider engaging in shared and informed decision process concerning screening for prostate cancer.