Amir Qaseem, MD, PhD, MHA; Michael J. Barry, MD; Thomas D. Denberg, MD, PhD; Douglas K. Owens, MD, MS; Paul Shekelle, MD, PhD; for the Clinical Guidelines Committee of the American College of Physicians (*)
Note: Clinical guidance statements are “guides” only and may not apply to all patients and clinical situations. Thus, they are not intended to override clinicians' judgment. All ACP clinical guidance statements are considered automatically withdrawn or invalid 5 years after publication, or once an update has been issued.
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Potential Conflicts of Interest: Dr. Barry: Board membership and employment: Informed Medical Decisions Foundation; Royalties: Health Dialog. Dr. Owens: Support for travel to meetings: ACP. Dr. Shekelle: Consultancy: ECRI Institute; Employment: Veterans Affairs; Grants/grants pending (money to institution): Agency for Healthcare Research and Quality, Veterans Affairs, Centers for Medicare & Medicaid Services, National Institute of Nursing Research, Office of the National Coordinator; Royalties: UpToDate. All other authors have no disclosures. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-2408. A record of conflicts of interest is kept for each Clinical Guidelines Committee meeting and conference call and can be viewed at www.acponline.org/clinical_information/guidelines/guidelines/conflicts_cgc.htm.
Requests for Single Reprints: Amir Qaseem, MD, PhD, MHA, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Qaseem: 190 N. Independence Mall West, Philadelphia, PA 19106.
Dr. Barry: 50 Staniford Street, 9th Floor, Boston, MA 02114.
Dr. Denberg: 275 Grove Street, Auburndale, MA 02466.
Dr. Owens: 117 Encina Commons, Stanford, CA 94305.
Dr. Shekelle: 11301 Wilshire Boulevard, Los Angeles, CA 90073.
Author Contributions: Conception and design: A. Qaseem, M.J. Barry, T.D. Denberg, D.K. Owens, P. Shekelle.
Analysis and interpretation of the data: A. Qaseem, M.J. Barry, T.D. Denberg, D.K. Owens.
Drafting of the article: A. Qaseem, T.D. Denberg.
Critical revision for important intellectual content: A. Qaseem, M.J. Barry, T.D. Denberg, D.K. Owens, P. Shekelle.
Final approval of the article: A. Qaseem, M.J. Barry, T.D. Denberg, D.K. Owens, P. Shekelle.
Provision of study materials or patients: A. Qaseem.
Statistical expertise: A. Qaseem.
Administrative, technical, or logistic support: A. Qaseem.
Collection and assembly of data: A. Qaseem, M.J. Barry.
Prostate cancer is an important health problem in men. It rarely causes death in men younger than 50 years; most deaths associated with it occur in men older than 75 years. The benefits of screening with the prostate-specific antigen (PSA) test are outweighed by the harms for most men. Prostate cancer never becomes clinically significant in a patient's lifetime in a considerable proportion of men with prostate cancer detected with the PSA test. They will receive no benefit and are subject to substantial harms from the treatment of prostate cancer. The American College of Physicians (ACP) developed this guidance statement for clinicians by assessing current prostate cancer screening guidelines developed by other organizations. ACP believes that it is more valuable to provide clinicians with a rigorous review of available guidelines rather than develop a new guideline on the same topic when several guidelines are available on a topic or when existing guidelines conflict. The purpose of this guidance statement is to critically review available guidelines to help guide internists and other clinicians in making decisions about screening for prostate cancer. The target patient population for this guidance statement is all adult men.
This guidance statement is derived from an appraisal of available guidelines on screening for prostate cancer. Authors searched the National Guideline Clearinghouse to identify prostate cancer screening guidelines in the United States and selected 4 developed by the American College of Preventive Medicine, American Cancer Society, American Urological Association, and U.S. Preventive Services Task Force. The AGREE II (Appraisal of Guidelines, Research and Evaluation in Europe) instrument was used to evaluate the guidelines.
ACP recommends that clinicians inform men between the age of 50 and 69 years about the limited potential benefits and substantial harms of screening for prostate cancer. ACP recommends that clinicians base the decision to screen for prostate cancer using the prostate-specific antigen test on the risk for prostate cancer, a discussion of the benefits and harms of screening, the patient's general health and life expectancy, and patient preferences. ACP recommends that clinicians should not screen for prostate cancer using the prostate-specific antigen test in patients who do not express a clear preference for screening.
ACP recommends that clinicians should not screen for prostate cancer using the prostate-specific antigen test in average-risk men under the age of 50 years, men over the age of 69 years, or men with a life expectancy of less than 10 to 15 years.
Table 1. Mean Guideline Scores and Scaled Domain Scores Across Domains of AGREE II Instrument
ACPM concludes that there is insufficient evidence to recommend routine population screening with digital rectal examination or prostate-specific antigen.
ACPM concludes that clinicians caring for men, especially African American men and those with a family history of prostate cancer, should provide information about potential benefits and risks of prostate cancer screening, and the limitations of current evidence for screening in order to maximize informed decision-making. While the usual age for prostate cancer screening is between 50–70 years in average risk men, it has been suggested that those who are at high risk may benefit from earlier screening beginning at age 45, while even higher risk men (those with two or more first-degree relatives with prostate cancer before age 65) should be screened at age 40.
ACS recommends that asymptomatic men who have at least a 10-year life expectancy have an opportunity to make an informed decision with their health care provider about screening for prostate cancer after they receive information about the uncertainties, risks, and potential benefits associated with prostate cancer screening.
ACS recommends that prostate cancer screening should not occur without an informed decision-making process. Men at average risk should receive this information beginning at age 50 years. Men in higher risk groups should receive this information before age 50 years. Men should either receive this information directly from their health care providers or be referred to reliable and culturally appropriate sources.
AUA recommends that the decision to use PSA for the early detection of prostate cancer should be individualized. Patients should be informed of the known risks and the potential benefits.
AUA recommends that men who wish to be screened for prostate cancer should have both a PSA test and a DRE.
AUA recommends that early detection and risk assessment of prostate cancer should be offered to asymptomatic men 40 years of age or older who wish to be screened and have an estimated life expectancy of more than 10 years.
USPSTF recommends against PSA-based screening for prostate cancer.
Table 2. Free Decision Aids for Prostate Cancer Screening
The American College of Physicians guidance statement on screening for prostate cancer.
DRE = digital rectal examination; PSA = prostate-specific antigen.
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Men between the ages of 50 and 69 should discuss the limited benefits and substantial harms of the prostate-specific antigen test with their doctor before undergoing screening for prostate cancer.
Qaseem A, Barry MJ, Denberg TD, Owens DK, Shekelle P, for the Clinical Guidelines Committee of the American College of Physicians. Screening for Prostate Cancer: A Guidance Statement From the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2013;158:761–769. doi: 10.7326/0003-4819-158-10-201305210-00633
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Published: Ann Intern Med. 2013;158(10):761-769.
Cancer Screening/Prevention, Guidelines, Hematology/Oncology, High Value Care, Prevention/Screening.
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