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Prostate Cancer Screening (Clinical)

Prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer is one of the most common cancers affecting men. In the United States, the lifetime risk of being diagnosed with prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer is around 11%, and the lifetime risk of dying from this condition is 2.5%. Prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer is a slow-growing cancer that takes years (even decades) to develop into advanced disease, and many men remain asymptomatic and die from other medical conditions. The preferred method of screening Screening Preoperative Care is with prostate-specific antigen Prostate-specific antigen A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer ( PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer) testing. Conditions such as prostatitis Prostatitis Prostatitis is inflammation or an irritative condition of the prostate that presents as different syndromes: acute bacterial, chronic bacterial, chronic prostatitis/chronic pelvic pain, and asymptomatic. Bacterial prostatitis is easier to identify clinically and the management (antibiotics) is better established. Prostatitis and benign Benign Fibroadenoma prostatic hyperplasia Hyperplasia An increase in the number of cells in a tissue or organ without tumor formation. It differs from hypertrophy, which is an increase in bulk without an increase in the number of cells. Cellular Adaptation are also associated with elevated PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer levels. Thus, confirmation of the diagnosis may be pursued through prostate biopsy Prostate Biopsy Prostate Cancer, which carries risks. The current recommendation is for the patient and clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship to have a discussion about the risks and benefits, and to assess the patient’s risk for prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer. Factors considered in the discussion include the patient’s age, life expectancy Life expectancy Based on known statistical data, the number of years which any person of a given age may reasonably expected to live. Population Pyramids, family history Family History Adult Health Maintenance, comorbid conditions, and individual values about screening Screening Preoperative Care and management-associated consequences.

Last updated: Apr 24, 2023

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Overview

Prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer[1-3]

  • Cancer of the prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. gland
  • Adenocarcinoma accounts for > 90% of cases.

Epidemiology[1-3,6]

  • Worldwide:
    • 2nd most common cancer diagnosis in men
    • > 1.3 million cases diagnosed annually
  • In the United States:
    • 3rd leading cause of cancer in men
    • Approximately 192,000 cases diagnosed annually
    • Lifetime risk of a prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer diagnosis is 11%.
    • Lifetime risk of dying from prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer is 2.5%.
  • 5-year survival after diagnosis:
    • Localized disease or regional spread: nearly 100%
    • Distant metastatic disease: 31%

Risk factors

Inherent factors (major factors):[2-4]

  • Age:
    • Rare before 40 years of age
    • Peaks between 65 and 74 years of age
  • More common, and earlier onset, in African Americans
  • Family history Family History Adult Health Maintenance of prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer, particularly in 1st-degree relatives who were diagnosed at < 65 years of age
  • Family history Family History Adult Health Maintenance of other heritable cancers:
    • Breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer, BRCA1 and BRCA2 gene Gene A category of nucleic acid sequences that function as units of heredity and which code for the basic instructions for the development, reproduction, and maintenance of organisms. Basic Terms of Genetics mutations
    • Melanoma Melanoma Melanoma is a malignant tumor arising from melanocytes, the melanin-producing cells of the epidermis. These tumors are most common in fair-skinned individuals with a history of excessive sun exposure and sunburns. Melanoma
    • Colorectal cancer Colorectal cancer Colorectal cancer (CRC) is the 2nd leading cause of cancer-related deaths in the United States. Colorectal cancer is a heterogeneous disease that arises from genetic and epigenetic abnormalities, with influence from environmental factors. Colorectal Cancer, Lynch syndrome Lynch syndrome Lynch syndrome, also called hereditary non-polyposis colorectal cancer (HNPCC), is the most common inherited colon cancer syndrome, and carries a significantly increased risk for endometrial cancer and other malignancies. Lynch syndrome has an autosomal dominant inheritance pattern involving pathogenic variants in one of the mismatch repair (MMR) genes or epithelial cell adhesion molecule (EpCAM). Lynch syndrome
    • Ovarian cancer Ovarian cancer Ovarian cancer is a malignant tumor arising from the ovarian tissue and is classified according to the type of tissue from which it originates. The 3 major types of ovarian cancer are epithelial ovarian carcinomas (EOCs), ovarian germ cell tumors (OGCTs), and sex cord-stromal tumors (SCSTs). Ovarian Cancer
    • Pancreatic cancer

Medical factors:[2-4]

  • Obesity Obesity Obesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity
  • 5-alpha reductase inhibitors (e.g., finasteride Finasteride An orally active 3-oxo-5-alpha-steroid 4-dehydrogenase inhibitor. It is used as a surgical alternative for treatment of benign prostatic hyperplasia. Androgens and Antiandrogens)
    • Prostate-specific antigen Prostate-specific antigen A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer ( PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer) levels
    • ↑ High-grade prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer risk
  • Trichomonas Trichomonas A genus of parasitic flagellate eukaryotes distinguished by the presence of four anterior flagella, an undulating membrane, and a trailing flagellum. Nitroimidazoles vaginalis infection

Social and environmental factors:[2-4]

  • High-fat, low-vegetable diet
  • Cigarette smoking Smoking Willful or deliberate act of inhaling and exhaling smoke from burning substances or agents held by hand. Interstitial Lung Diseases
  • Exposure to Agent Orange Agent orange A herbicide that contains equal parts of 2, 4-dichlorophenoxyacetic acid (2, 4-d) and 2, 4, 5-trichlorophenoxyacetic acid (2, 4, 5-t), as well as traces of the contaminant 2, 3, 7, 8-tetrachlorodibenzo-p-dioxin. Herbicide Poisoning:
    • Herbicide and defoliant chemical used during the Vietnam War between 1965 and 1972
    • Associated with more aggressive cancer
  • Exposure to chlordecone:
    • Insecticide used between 1973 and 2003 in the Caribbean
    • Binds estrogen Estrogen Compounds that interact with estrogen receptors in target tissues to bring about the effects similar to those of estradiol. Estrogens stimulate the female reproductive organs, and the development of secondary female sex characteristics. Estrogenic chemicals include natural, synthetic, steroidal, or non-steroidal compounds. Ovaries: Anatomy receptors Receptors Receptors are proteins located either on the surface of or within a cell that can bind to signaling molecules known as ligands (e.g., hormones) and cause some type of response within the cell. Receptors, which may contribute to malignancy Malignancy Hemothorax development

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Screening Rationale

Individualized screening Screening Preoperative Care[6-12]

  • Screening Screening Preoperative Care offers a small potential benefit in reducing the chance of death from prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer. 
  • The potential benefit will take many years, even decades, while the harms occur soon after screening Screening Preoperative Care starts.
  • Prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer often has a slow growth rate, in which:
    • Half of cases do not present clinically.
    • Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship frequently die from other medical conditions.
  • Each patient is encouraged to decide on the potential benefits and harms discussed based on his own values.
  • Decision-making is encouraged to be shared between patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship and their physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship.

Benefits of screening Screening Preoperative Care[6-12]

  • Goals:
    • Identify high-risk, localized prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer that can be successfully treated 
    • Prevent prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer-related morbidity Morbidity The proportion of patients with a particular disease during a given year per given unit of population. Measures of Health Status and mortality Mortality All deaths reported in a given population. Measures of Health Status, including advanced or metastatic disease
  • Benefits of PSA-based screening Screening Preoperative Care:
    • In men aged 55–69 years, screening Screening Preoperative Care may prevent 1.3 deaths from prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer per 1,000 men screened over 13 years.
    • Screening Screening Preoperative Care may prevent 3 cases of metastatic prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer per 1,000 men.
    • However, trials have not shown a reduction in all-cause mortality Mortality All deaths reported in a given population. Measures of Health Status.

Risks of screening Screening Preoperative Care[6-12]

  • Harms of screening Screening Preoperative Care:
    • Frequent false positive False positive An FP test result indicates that a person has the disease when they do not. Epidemiological Values of Diagnostic Tests results
    • Leads to over-diagnosis (cancer diagnosed in men who otherwise would not have symptomatic cancer in their lifetime)
  • Potential harms of diagnostic biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma:
    • Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways
    • Infection
    • Rectal bleeding
    • Urinary obstruction
    • Psychological harm
  • Potential harms of cancer management:
    • Erectile dysfunction Erectile Dysfunction Erectile dysfunction (ED) is defined as the inability to achieve or maintain a penile erection, resulting in difficulty to perform penetrative sexual intercourse. Local penile factors and systemic diseases, including diabetes, cardiac disease, and neurological disorders, can cause ED. Erectile Dysfunction (up to 50% of patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship)
    • Urinary incontinence Urinary incontinence Urinary incontinence (UI) is involuntary loss of bladder control or unintentional voiding, which represents a hygienic or social problem to the patient. Urinary incontinence is a symptom, a sign, and a disorder. The 5 types of UI include stress, urge, mixed, overflow, and functional. Urinary Incontinence
    • Bowel dysfunction
    • Psychological harm 

Screening Strategy: PSA

Prostate-specific antigen Prostate-specific antigen A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer is currently the only recommended screening Screening Preoperative Care method for prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer.[9-15]

Background

  • A protein produced by normal and neoplastic prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cells
  • In healthy individuals, a small proportion will enter the bloodstream.

Causes of elevated serum PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer in prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer

  • An increased number of cells producing PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer, despite the fact that malignant cells generally make less PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer
  • Disruption in the normal architecture and basement membrane Basement membrane A darkly stained mat-like extracellular matrix (ecm) that separates cell layers, such as epithelium from endothelium or a layer of connective tissue. The ecm layer that supports an overlying epithelium or endothelium is called basal lamina. Basement membrane (bm) can be formed by the fusion of either two adjacent basal laminae or a basal lamina with an adjacent reticular lamina of connective tissue. Bm, composed mainly of type IV collagen; glycoprotein laminin; and proteoglycan, provides barriers as well as channels between interacting cell layers. Thin Basement Membrane Nephropathy (TBMN), allowing a higher proportion of PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer to enter the bloodstream

Interpretation of results[9,10]

  • There is no perfect PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer cutoff value that avoids all false positives or all false negatives.
    • False positive False positive An FP test result indicates that a person has the disease when they do not. Epidemiological Values of Diagnostic Tests rate: approximately 70%
      • Benign Benign Fibroadenoma causes of elevated PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer levels (contributing to false positive False positive An FP test result indicates that a person has the disease when they do not. Epidemiological Values of Diagnostic Tests rate):
        • Benign Benign Fibroadenoma prostatic hyperplasia Hyperplasia An increase in the number of cells in a tissue or organ without tumor formation. It differs from hypertrophy, which is an increase in bulk without an increase in the number of cells. Cellular Adaptation
        • Prostatitis Prostatitis Prostatitis is inflammation or an irritative condition of the prostate that presents as different syndromes: acute bacterial, chronic bacterial, chronic prostatitis/chronic pelvic pain, and asymptomatic. Bacterial prostatitis is easier to identify clinically and the management (antibiotics) is better established. Prostatitis 
        • Urinary retention Urinary retention Inability to empty the urinary bladder with voiding (urination). Delirium
        • Urologic procedures (cystoscopy, transurethral resection of the prostate Transurethral resection of the prostate Removal of all or part of the prostate, often using a cystoscope and/or resectoscope passed through the urethra. Benign Prostatic Hyperplasia)
        • Urinary tract Urinary tract The urinary tract is located in the abdomen and pelvis and consists of the kidneys, ureters, urinary bladder, and urethra. The structures permit the excretion of urine from the body. Urine flows from the kidneys through the ureters to the urinary bladder and out through the urethra. Urinary Tract: Anatomy infection
        • Vigorous exercise within 48 hours
        • Ejaculation within 48 hours
        • Anal sex Sex The totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism. Gender Dysphoria with 48 hours
    • False negative False negative An FN test result indicates a person does not have the disease when, in fact, they do. Epidemiological Values of Diagnostic Tests rate: approximately 15%
  • Positive: PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer ≥ 4 ng/mL
    • Most widely accepted standard, which tries to balance the trade-offs between sensitivity and specificity Sensitivity and Specificity Binary classification measures to assess test results. Sensitivity or recall rate is the proportion of true positives. Specificity is the probability of correctly determining the absence of a condition. Epidemiological Values of Diagnostic Tests
    • Test characteristics at this cutoff level:
      • For detection of any prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer: sensitivity = 21%; specificity = 91% 
      • For detection of high-grade cancer: sensitivity = 51%
    • Different cutoff levels for decision-making: age-specific reference ranges since PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer levels tend to increase with age
  • Negative: PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer < 4 ng/mL
    • Follow-up is needed
    • For patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship on a 5-alpha reductase inhibitor ( ARI ARI Measures of Risk):
      • Correction factor must be applied for accurate interpretation since ARIs lower PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer values.
      • If there is an increase in PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer level, they should be referred to urology.

Follow-up[7,12,13]

  • Retesting should be performed every 1–2 years if the level is < 4 ng/mL.
    • Interval recommendations vary between organizations. 
    • Can be individualized based on PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer level and the patient’s risk factors
  • Consider repeat testing in 6–8 weeks if the level is between 4 and 7 ng/mL to rule out benign Benign Fibroadenoma causes.
    • If the PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer is still elevated, or > 7 ng/mL on the initial screen, refer to urology. 
    • Further urologic workup can include:
      • Free:total (f/t) PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer ratio (f/t PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer < 10%–15% suggests cancer)
      • PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer density (ratio of PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer level to prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. volume measured on transrectal ultrasound)
      • Molecular and genomic analysis
      • Magnetic resonance imaging (MRI) of the prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid.
      • Prostate biopsy Prostate Biopsy Prostate Cancer

Screening Strategy: Digital Rectal Examination

Digital rectal examination Digital Rectal Examination A physical examination in which the qualified health care worker inserts a lubricated, gloved finger of one hand into the rectum and may use the other hand to press on the lower abdomen or pelvic area to palpate for abnormalities in the lower rectum, and nearby organs or tissues. The method is commonly used to check the lower rectum, the prostate gland in men, and the uterus and ovaries in women. Prostate Cancer Screening ( DRE DRE A physical examination in which the qualified health care worker inserts a lubricated, gloved finger of one hand into the rectum and may use the other hand to press on the lower abdomen or pelvic area to palpate for abnormalities in the lower rectum, and nearby organs or tissues. The method is commonly used to check the lower rectum, the prostate gland in men, and the uterus and ovaries in women. Prostate Cancer Screening) reaches the palpable lateral and posterior regions of the prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. gland, but not other areas where cancer can grow.[9-15]

  • No longer recommended for asymptomatic patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship
  • Low sensitivity and specificity Sensitivity and Specificity Binary classification measures to assess test results. Sensitivity or recall rate is the proportion of true positives. Specificity is the probability of correctly determining the absence of a condition. Epidemiological Values of Diagnostic Tests
  • Does not provide additional information to a PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer test
Digital rectal exam

Digital Rectal Examination for screening in Prostate cancer
PD

Image: “Digital rectal exam” by Unknown Illustrator. License: Public Domain

Screening Recommendations

Recommendations are based on US and international society guidelines. The decision to screen should be made as a shared decision between patient and physician. The decision should weigh the risks and benefits of PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer screening Screening Preoperative Care.

Table: Table: Societal guidelines for prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer screening Screening Preoperative Care[7,10-15]
Association (year) Age (years) PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer screening Screening Preoperative Care Detailed recommendations Frequency
NCCN (2022)[13] 44‒75 for average risk patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship Yes Initial evaluation should include:
  • History and physical exam
  • Family history Family History Adult Health Maintenance
  • Medications
  • History of prior prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. disease and screening Screening Preoperative Care
  • Family history Family History Adult Health Maintenance of BRCA 1 or 2 mutations
  • Risk assessment Risk assessment The qualitative or quantitative estimation of the likelihood of adverse effects that may result from exposure to specified health hazards or from the absence of beneficial influences. Preoperative Care includes:
  • Discussion of risks and benefits of prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. screening Screening Preoperative Care
  • Shared decision-making on baseline PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer and DRE DRE A physical examination in which the qualified health care worker inserts a lubricated, gloved finger of one hand into the rectum and may use the other hand to press on the lower abdomen or pelvic area to palpate for abnormalities in the lower rectum, and nearby organs or tissues. The method is commonly used to check the lower rectum, the prostate gland in men, and the uterus and ovaries in women. Prostate Cancer Screening
  • PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer < 1 ng/mL, DRE DRE A physical examination in which the qualified health care worker inserts a lubricated, gloved finger of one hand into the rectum and may use the other hand to press on the lower abdomen or pelvic area to palpate for abnormalities in the lower rectum, and nearby organs or tissues. The method is commonly used to check the lower rectum, the prostate gland in men, and the uterus and ovaries in women. Prostate Cancer Screening normal (if done), then repeat testing at 2‒4 year intervals
  • PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer 1–3 ng/mL, DRE DRE A physical examination in which the qualified health care worker inserts a lubricated, gloved finger of one hand into the rectum and may use the other hand to press on the lower abdomen or pelvic area to palpate for abnormalities in the lower rectum, and nearby organs or tissues. The method is commonly used to check the lower rectum, the prostate gland in men, and the uterus and ovaries in women. Prostate Cancer Screening normal (if done), then repeat testing at 1‒2 year intervals
  • PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer > 3 ng/mL and/or very suspicious DRE DRE A physical examination in which the qualified health care worker inserts a lubricated, gloved finger of one hand into the rectum and may use the other hand to press on the lower abdomen or pelvic area to palpate for abnormalities in the lower rectum, and nearby organs or tissues. The method is commonly used to check the lower rectum, the prostate gland in men, and the uterus and ovaries in women. Prostate Cancer Screening then:
    • Repeat PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer
    • DRE DRE A physical examination in which the qualified health care worker inserts a lubricated, gloved finger of one hand into the rectum and may use the other hand to press on the lower abdomen or pelvic area to palpate for abnormalities in the lower rectum, and nearby organs or tissues. The method is commonly used to check the lower rectum, the prostate gland in men, and the uterus and ovaries in women. Prostate Cancer Screening, if not performed
    • Consider urology referral for biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma
    40‒75 for:
  • People of color
  • Those with germline mutations that increase the risk for prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer
  • Those with suspicious family history Family History Adult Health Maintenance
  • Yes
    75 for those who are healthy with little to no comorbidities Comorbidities The presence of co-existing or additional diseases with reference to an initial diagnosis or with reference to the index condition that is the subject of study. Comorbidity may affect the ability of affected individuals to function and also their survival; it may be used as a prognostic indicator for length of hospital stay, cost factors, and outcome or survival. St. Louis Encephalitis Virus Yes
  • PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer < 4 ng/mL, DRE DRE A physical examination in which the qualified health care worker inserts a lubricated, gloved finger of one hand into the rectum and may use the other hand to press on the lower abdomen or pelvic area to palpate for abnormalities in the lower rectum, and nearby organs or tissues. The method is commonly used to check the lower rectum, the prostate gland in men, and the uterus and ovaries in women. Prostate Cancer Screening normal (if done), and no other indications for biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma, then repeat testing in at 1‒4-year intervals
  • PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer ≥ 4 ng/mL or very suspicious DRE DRE A physical examination in which the qualified health care worker inserts a lubricated, gloved finger of one hand into the rectum and may use the other hand to press on the lower abdomen or pelvic area to palpate for abnormalities in the lower rectum, and nearby organs or tissues. The method is commonly used to check the lower rectum, the prostate gland in men, and the uterus and ovaries in women. Prostate Cancer Screening, then:
    • Repeat PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer
    • DRE DRE A physical examination in which the qualified health care worker inserts a lubricated, gloved finger of one hand into the rectum and may use the other hand to press on the lower abdomen or pelvic area to palpate for abnormalities in the lower rectum, and nearby organs or tissues. The method is commonly used to check the lower rectum, the prostate gland in men, and the uterus and ovaries in women. Prostate Cancer Screening if not performed
    • Consider urology referral for biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma
    EAU (2021)[10,16]
  • > 50: general population
  • > 45: family history Family History Adult Health Maintenance of prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer or African decent
  • > 40: BRCA2 mutations
  • Yes
  • Do not order PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer testing without counseling patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship on the potential risks and benefits.
  • Offer an individualized risk-adapted strategy for early detection to a well-informed man with a life expectancy Life expectancy Based on known statistical data, the number of years which any person of a given age may reasonably expected to live. Population Pyramids of at least 10‒15 years.
  • Men with life expectancy Life expectancy Based on known statistical data, the number of years which any person of a given age may reasonably expected to live. Population Pyramids of < 15 years generally have no benefit from testing.
  • Risk-adapted strategy:
  • PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer > 1 ng/mL at 40 years of age: follow-up PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer in 2 years
  • PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer > 2 ng/mL at 60 years of age: follow-up PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer in 2 years
  • PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer > 3 ng/mL: obtain risk stratification (high risk→ MRI)
  • USPSTF (2018)[7] 55‒69 The decision to be screened for prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer should be an individual one.
  • Clinicians should inform men about the potential benefits and harms of PSA-based screening Screening Preoperative Care.
  • Current evidence does not support separate recommendations for high-risk populations.
  • No recommendations
    > 70 No No mortality Mortality All deaths reported in a given population. Measures of Health Status benefit of PSA-based screening Screening Preoperative Care
    AUA (2018)[11] < 40 No
  • Low prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency of clinically detectable prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer
  • No evidence demonstrating benefit of screening Screening Preoperative Care
  • Likely the same harms of screening Screening Preoperative Care as in other age groups
  • No recommendations
    40-54 No
  • No routine screening Screening Preoperative Care in average-risk men in this age group.
  • Decisions regarding prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer screening Screening Preoperative Care should be individualized for men younger than age 55 years at higher risk.
  • For those who choose screening Screening Preoperative Care, a routine screening Screening Preoperative Care interval of 2 years or more may be preferred over annual screening Screening Preoperative Care to preserve the majority of the benefits and reduce over-diagnosis and false positives.
    55-69 The decision to be screened for prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer should be an individual one.
  • Shared decision-making, weighing benefits and harms, is strongly recommended for men considering PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer screening Screening Preoperative Care, then proceeding based on individual values and preferences.
  • The greatest benefit of screening Screening Preoperative Care appears to be in men ages 55–69 years.
  • ≥ 70 No
  • No routine PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer screening Screening Preoperative Care in men age ≥ 70 years or any man with less than a 10–15 year life expectancy Life expectancy Based on known statistical data, the number of years which any person of a given age may reasonably expected to live. Population Pyramids.
  • Some men age ≥ 70 years who are in excellent health may benefit from prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer screening Screening Preoperative Care.
  • No recommendations
    ACP (2013)[15] < 50 No Recommendation to not screen for prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer via PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer in average-risk men in this age group. No recommendations
    50‒69 Patient preference after discussion
  • Inform men about the limited potential benefits and substantial harms of screening Screening Preoperative Care.
  • Discuss the patient’s general health and life expectancy Life expectancy Based on known statistical data, the number of years which any person of a given age may reasonably expected to live. Population Pyramids, and patient’s preferences.
  • Do not screen using the PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer test in patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship who do not express a clear preference for screening Screening Preoperative Care.
  • ≥ 70 No Recommendation to not screen for prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer via PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer in men over the age of 69 years, or those with a life expectancy Life expectancy Based on known statistical data, the number of years which any person of a given age may reasonably expected to live. Population Pyramids of less than 10–15 years.
    Associations:
  • NCCN: National Comprehensive Cancer Network
  • EAU: European Association of Urology
  • USPSTF: United States Preventive Services Task Force
  • AUA: American Urological Association
  • ACP: American College of Physicians
  • Other:
  • DRE: digital rectal examination
  • PSA: prostate-specific antigen
  • References

    1. Hoffman, R. M. (2020). Screening for prostate cancer. UpToDate. Retrieved December 20, 2020, from https://www.uptodate.com/contents/screening-for-prostate-cancer
    2. Mark, J. R. (2019). Prostate cancer. MSD Manual Professional Version. https://www.msdmanuals.com/professional/genitourinary-disorders/genitourinary-cancer/prostate-cancer
    3. Tracy, C. R., Brooks, N. A., and Said, M. (2020). Prostate cancer. Medscape. https://emedicine.medscape.com/article/1967731-overview
    4. Sartor, A. O. (2020). Risk factors for prostate cancer. UpToDate. Retrieved December 20, 2020, from https://www.uptodate.com/contents/risk-factors-for-prostate-cancer
    5. Jahn, J. L., Giovannucci, E. L., Stampfer, M. J. (2015). The high prevalence of undiagnosed prostate cancer at autopsy: implications for epidemiology and treatment of prostate cancer in the prostate-specific antigen-era. International Journal of Cancer, 137(12), 2795–2802. https://doi.org/10.1002/ijc.29408
    6. American Cancer Society. (2019). Recommendations for prostate cancer early detection. Retrieved November 8, 2022, from https://www.cancer.org/cancer/prostate-cancer/detection-diagnosis-staging/acs-recommendations.html
    7. U.S. Preventive Services Task Force. (2018). Final recommendation statement: screening for prostate cancer. Retrieved November 9, 2022, from https://www.uspreventiveservicestaskforce.org/uspstf/announcements/final-recommendation-statement-screening-prostate-cancer
    8. American Cancer Society (2020). Testing for Prostate Cancer. Retrieved October 21, 2022, from https://www.cancer.org/content/dam/cancer-org/cancer-control/en/booklets-flyers/testing-for-prostate-cancer-handout.pdf
    9. GOV.UK (2022). Advising men without symptoms of prostate disease who ask about the PSA test. Retrieved October 21, 2022, from https://www.gov.uk/government/publications/prostate-specific-antigen-testing-explanation-and-implementation/advising-well-men-about-the-psa-test-for-prostate-cancer-information-for-gps
    10. European Association of Urology (2018). EAU guidelines on prostate cancer. Retrieved October 21, 2022, from https://uroweb.org/guidelines/prostate-cancer
    11. Carter, H. B., Albertsen, P. C., Barry, M. J., et al. Early detection of prostate cancer (2013, reviewed 2018). Journal of Urology, 190, 419 Retrieved October 21, 2022, from https://www.auanet.org/guidelines-and-quality/guidelines/prostate-cancer-early-detection-guideline#x2636
    12. Rendon, R. A., Mason, R. J., Marzouk, K., Finelli, A., Saad, F., So, A., Violette, P. D., Breau, R. H. (2017). Canadian Urological Association recommendations on prostate cancer screening and early diagnosis. Canadian Urological Association Journal, 11(10), 298–309. https://doi.org/10.5489/cuaj.4888
    13. National Comprehensive Cancer Network (2022). Prostate cancer early detection guidelines. Retrieved October 21, 2022, from https://www.nccn.org/professionals/physician_gls/pdf/prostate_detection.pdf
    14. Canadian Task Force on Preventive Health Care (2016). Prostate cancer—clinician summary. Retrieved October 24, 2022, from https://canadiantaskforce.ca/prostate-cancer-clinician-summary/
    15. Qaseem, A., Barry, M. J., Denberg, T. D., Owens, D. K., Shekelle, P. (2013). Screening for prostate cancer: a guidance statement from the Clinical Guidelines Committee of the American College of Physicians. Annals of Internal Medicine, 158(10), 761–769. https://doi.org/10.7326/0003-4819-158-10-201305210-00633
    16. Van Poppel, H., Roobol, M. J., Chapple, C. R., Catto, J., N’Dow, J., Sønksen, J., Stenzl, A., Wirth, M. (2021). Prostate-specific antigen testing as part of a risk-adapted early detection strategy for prostate cancer: European Association of Urology position and recommendations for 2021. European Urology, 80(6), 703–711. https://doi.org/10.1016/j.eururo.2021.07.024

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