Disclosures: Richard M Hoffman, MD, MPH Nothing to disclose. Joann G Elmore, MD, MPH Grant/Research Support: NIH Robert Wood Johnson Foundation [research]. Consultant/Advisory Boards: Non-profit Informed Medical Decisions Foundation/Healthwise [Patient Decision Aids]. Other Financial Interest: Elsevier, Inc [Royalties from textbook]. Michael P O'Leary, MD, MPH Nothing to disclose. David M Rind, MD Employee of UpToDate, Inc. Equity Ownership/Stock Options (Spouse): Bonfire Development Advisors [CBT (iCBT)].
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence.
INTRODUCTION — Prostate cancer is common and a frequent cause of cancer death. In the United States, prostate cancer is the most commonly diagnosed visceral cancer; in 2015, there are expected to be about 221,000 new prostate cancer diagnoses and about 27,500 prostate cancer deaths . Prostate cancer is second only to nonmelanoma skin cancer and lung cancer as the leading cause of cancer and cancer death, respectively, in United States men. Worldwide, in 2012 there were estimated to be 1,112,000 new cases of prostate cancer and 308,000 prostate cancer deaths, making it the second most commonly diagnosed cancer in men and the fifth leading cause of male cancer death .
For an American male, the lifetime risk of developing prostate cancer is 16 percent, but the risk of dying of prostate cancer is only 2.9 percent . Many more cases of prostate cancer do not become clinically evident, as indicated in autopsy series, where prostate cancer is detected in about 30 percent of men age 55, and about 60 percent of men by age 80  (see "Risk factors for prostate cancer", section on 'Age'). These data suggest that prostate cancer often grows so slowly that most men die of other causes before the disease becomes clinically advanced.
Prostate cancer survival is related to many factors, especially the extent of tumor at the time of diagnosis. The five-year relative survival among men with cancer confined to the prostate (localized) or with just regional spread is 100 percent compared with 31.9 percent among those diagnosed with distant metastases . While men with advanced stage disease may benefit from palliative treatment, their tumors are generally not curable.
Thus, a screening program that could accurately identify asymptomatic men with aggressive localized tumors might be expected to substantially reduce prostate cancer morbidity, including urinary obstruction and painful metastases, and mortality.
Prostate-specific antigen (PSA) testing revolutionized prostate cancer screening. Although PSA was originally introduced as a tumor marker to detect cancer recurrence or disease progression following treatment, it became widely adopted for cancer screening by the early 1990s. Subsequently, professional societies issued guidelines supporting routine prostate cancer screening with PSA [5,6]. PSA testing led to a dramatic increase in the incidence of prostate cancer, peaking in 1992 (figure 1) . The majority of these newly-diagnosed cancers were clinically localized (figure 2), which led to an increase in radical prostatectomy and radiation therapy, aggressive treatments intended to cure these early-stage cancers [8-11].
However, prostate cancer screening has been a controversial issue because decisions were made about adopting PSA testing in the absence of efficacy data from randomized trials . Subsequently, the European Randomized Study of Screening for Prostate Cancer (ERSPC) reported a small absolute survival benefit with PSA screening after nine years of follow-up ; however, 48 additional patients would need to be diagnosed with prostate cancer to prevent one prostate cancer death. Although the report did not address quality of life outcomes, considerable data show the potential harms from aggressive treatments, including erectile dysfunction, urinary incontinence, and bowel problems . Further sustaining the uncertainty surrounding screening, a report from the large United States trial, the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, published concurrently with the European trial, found no benefit for annual PSA and digital rectal examination (DRE) screening after 7 to 10 years of follow-up .
This topic reviews the screening tests that are available for prostate cancer, the efficacy of screening, and the recommendations of major medical associations and societies regarding screening for prostate cancer. Risk factors and the clinical manifestations and diagnosis of prostate cancer are discussed separately. (See "Risk factors for prostate cancer" and "Clinical presentation and diagnosis of prostate cancer".)
PROSTATE SPECIFIC ANTIGEN (PSA) — PSA is a glycoprotein produced by prostate epithelial cells. PSA levels may be elevated in men with prostate cancer because PSA production is increased and because tissue barriers between the prostate gland lumen and the capillary are disrupted, releasing more PSA into the serum. (See "Measurement of prostate specific antigen".)
Studies have estimated that PSA elevations can precede clinical disease by 5 to 10 years [16,17] or even longer . However, PSA is also elevated in a number of benign conditions (table 1), particularly benign prostatic hyperplasia (BPH) and prostatitis. (See "Clinical manifestations and diagnostic evaluation of benign prostatic hyperplasia" and "Acute bacterial prostatitis".)
Measuring PSA — In addition to the PSA elevations seen with BPH, there are transient causes of PSA elevation (table 1), some of which are significant enough to affect the performance of PSA measurement as a screening test. We describe PSA values in ng/mL throughout this topic, but this is equivalent to the SI units of mcg/L; that is, 4 ng/mL = 4 mcg/L. (See "Measurement of prostate specific antigen", section on 'Causes of an elevated serum PSA'.)
●Digital rectal examination (DRE) has minimal effect on PSA levels, leading to transient elevations of only 0.26 to 0.4 ng/mL, and PSA can be measured immediately after DRE [23,24].
●Ejaculation can increase PSA levels by up to 0.8 ng/mL, though levels return to normal within 48 hours [25,26]. We do not usually ask men to abstain from sexual activity prior to PSA measurement. However, if an initial measurement is high enough to potentially prompt an intervention (ie, biopsy), but close to a threshold value, it is appropriate to repeat the PSA measurement after having the man abstain from ejaculation for at least 48 hours.
●Bacterial prostatitis may elevate PSA levels , but they generally return to baseline six to eight weeks after symptoms resolve. Asymptomatic prostatic inflammation can also elevate PSA levels , but this diagnosis is made on biopsy and so cannot generally be used to defer screening tests .
●Prostate biopsy may elevate PSA levels by a median of 7.9 ng/mL within 4 to 24 hours following the procedure . Levels will remain elevated for two to four weeks. Similarly, a transurethral resection of the prostate (TURP) can elevate PSA levels by a median of 5.9 ng/mL . Levels will remain elevated for a median time of approximately three weeks. A screening PSA test should not be performed for at least six weeks following either of these procedures.
●Acute urinary retention may elevate PSA levels, but the levels can be expected to decrease by 50 percent within one to two days following resolution. A screening PSA test should not be performed for at least two weeks following an episode of acute urinary retention.
The five-alpha reductase inhibitors finasteride and dutasteride lower PSA levels. Finasteride lowers PSA levels by a median 50 percent within six months of use, though the effects can vary widely, ranging from –81 percent to +20 percent ; dutasteride has been reported to reduce PSA levels by 48 to 57 percent . Some experts recommend doubling the measured PSA value before interpreting the result for patients on finasteride . Longitudinal results from the Prostate Cancer Prevention Trial suggest that PSA values be corrected by a factor of 2 for the first two years of finasteride therapy, and by 2.5 for longer-term use . Results from the Reduction by Dutasteride of Prostate Cancer Events (REDUCE) trial suggested that a rise in PSA levels while on dutasteride is associated with a higher risk for prostate cancer [33,34].
Test performance — Determining the accuracy of PSA testing has been difficult because most men with normal PSA values will not undergo biopsy unless their digital examination is abnormal. This work-up bias tends to overestimate sensitivity and underestimate specificity . Performance can also be overestimated because PSA often detects clinically-unimportant cancers. (See 'Overdiagnosis' below.)
Another problem in assessing the accuracy of PSA is that the transrectal needle biopsy is not a perfect gold standard. Investigators have suggested that the false-negative rate can range from 10 to 20 percent [36,37], though the recent trend towards obtaining 12 samples has increased the detection rate [38,39].
Additionally, protocols that use large numbers of biopsies to evaluate patients with an elevated PSA may be detecting incidental cancers that were not the etiology of the PSA elevation. One review that assumed that nonpalpable cancers smaller than 1.0 cm3 would not cause elevated PSA levels estimated that approximately 25 percent of cancers detected by PSA screening were too small to have accounted for the PSA rise that prompted a biopsy .
The diagnostic performance of PSA ideally needs to be calibrated against clinically-important cancers. However, there is no consensus on defining such cancers. Although many experts consider tumors with Gleason scores ≥7 and volumes >0.5 cm3 to have a greater risk for progression, there is no certainty that these cancers will lead to early death or reduce quality of life .
Sensitivity and specificity — The traditional cutoff for an abnormal PSA level in the major screening studies has been 4.0 ng/mL [42-45]. The American Cancer Society systematically reviewed the literature assessing PSA performance . In a pooled analysis, the estimated sensitivity of a PSA cutoff of 4.0 ng/mL was 21 percent for detecting any prostate cancer and 51 percent for detecting high-grade cancers (Gleason ≥8). Using a cutoff of 3.0 ng/mL increased these sensitivities to 32 and 68 percent, respectively. The estimated specificity was 91 percent for a PSA cutoff of 4.0 ng/mL and 85 percent for a 3.0 ng/mL cutoff. PSA has poorer discriminating ability in men with symptomatic benign prostatic hyperplasia .
Positive predictive value — The test performance statistic that has been best characterized by screening studies is the positive predictive value: the proportion of men with an elevated PSA who have prostate cancer.
Overall, the positive predictive value for a PSA level >4.0 ng/mL is approximately 30 percent, meaning that slightly less than one in three men with an elevated PSA will have prostate cancer detected on biopsy [42,48,49]. For PSA levels between 4.0 to 10.0 ng/mL, the positive predictive value is about 25 percent ; this increases to 42 to 64 percent for PSA levels >10 ng/mL [48,50].
However, nearly 75 percent of cancers detected within the "gray zone" of PSA values between 4.0 to 10.0 ng/mL are organ confined and potentially curable . The proportion of organ-confined cancers drops to less than 50 percent for PSA values above 10.0 ng/mL . Thus, detecting the curable cancers in men with PSA levels less than 10.0 ng/mL presents a diagnostic challenge because the high false-positive rate leads to many unnecessary biopsies.
Negative predictive value — The Prostate Cancer Prevention Trial, which biopsied men with normal PSA levels, estimated a negative predictive value of 85 percent for a PSA value ≤4.0 ng/mL .
Effect of lowering PSA cutoffs — Some investigators have suggested using a lower PSA cutoff because some men with PSA levels below 4 ng/mL and normal digital rectal examinations are found to have prostate cancer [52-55].
In a subset analysis from the placebo arm of the Prostate Cancer Prevention Trial, 449 of 2950 men (15.2 percent) ages 62 to 91 years who had consistently normal PSA levels and digital rectal examinations during the seven years of annual screening had prostate cancer on an end-of-study biopsy; overall, seven (1.6 percent of cancers) had high-grade prostate cancer with a Gleason score of 8 or higher . Among the 675 men with a PSA concentration between 2.1 and 4.0 ng/mL, 167 (24.7 percent) had prostate cancer, and four (3.5 percent of cancers) had prostate cancer with a Gleason score of 8 or higher.
These observations indicate that there is not a clear cutpoint between "normal" and "abnormal" PSA levels. The Prostate Cancer Prevention Trial found that for biopsies performed during follow-up in the control group even a PSA cutoff of 1.1 ng/mL would miss 17 percent of cancers, including 5 percent of poorly differentiated cancers . Thus, any choice of PSA cutoff involves a tradeoff between sensitivity and specificity. While lowering the PSA cutoff would improve test sensitivity, a lower PSA cutoff would also reduce specificity, leading to far more false-positive tests and unnecessary biopsies. It has been projected that if the PSA threshold were to be lowered to 2.5 ng/mL, the number of men defined as abnormal would double, to up to six million in the US . Additionally, many of the cancers detected at these lower levels may never have become clinically evident, thereby leading to overdiagnosis and overtreatment .
There is also evidence that diagnosing prostate cancer at low PSA levels does not affect outcome. A study of 875 men undergoing radical prostatectomy found only a limited association between preoperative PSA levels of 2 to 9 ng/mL and cure rates . The disease-free survival curves did not significantly diverge until the preoperative PSA levels reached 7 ng/mL, suggesting that diagnosing cancers at a lower PSA level may be unnecessary. Most of the PSA elevation below 7 ng/mL was attributed to benign hyperplastic tissue. The investigators emphasized the need for a better serum marker to identify early-stage aggressive cancers.
Serial PSA measurements — Both detection rates and positive predictive values decline substantially with serial testing [60-63]:
●During four rounds of annual PSA screening in the PLCO trial, the number of cancers detected per 1000 men decreased from 14.2 to 9.3 . Similarly, the positive predictive value of a PSA level >4.0 ng/mL decreased from 44.5 to 34.9 percent.
●The cancer detection rate for PSA in the ERSPC, which used a 4-year screening interval, decreased from 5.1 percent in the first round of screening to 4.4 percent in the second round . The positive predictive value for a PSA level of 3.0 ng/mL or greater decreased from 29.2 to 19.9 percent.
Studies also found that repeated testing increases the likelihood that detected tumors will be clinically organ-confined and be moderately or well differentiated [43,62-64] (see 'Frequency and method of screening' below):
●In the PLCO, the proportion of screening-detected cancers diagnosed at clinical stage I or II increased from 94.2 percent in round one to 98.5 percent in round 2, while the proportion with Gleason scores ≥7 decreased from 10.0 to 6.8 percent .
●In the ERSPC, the proportion of clinical stage I and II cancers increased from 81.5 to 96.3 percent, while the proportion of poorly-differentiated cancers decreased from 8.1 to 3.3 percent .
Improving the accuracy of PSA — Numerous strategies have been proposed to improve the diagnostic performance of PSA when levels are less than 10.0 ng/mL. These strategies include measuring PSA velocity (change in PSA over time), PSA density (PSA per unit volume of prostate), free PSA, complexed PSA, and using age- and race-specific reference ranges . We suggest not routinely using any of these strategies in deciding which men to refer for biopsy. (See "Measurement of prostate specific antigen".)
PSA velocity — PSA increases more rapidly in men with prostate cancer than in healthy men. The Baltimore Longitudinal Study of Aging (BLSA) found that men with a PSA rate of change (PSA velocity) greater than 0.75 ng/mL/year were at increased risk of being diagnosed with prostate cancer and that PSA velocity was more specific than a 4.0 ng/mL PSA cutoff (90 versus 60 percent specificity) . The study results, though, were based on analyzing the banked serum of only 18 cancer cases. Furthermore, there are significant short-term physiologic variations in the PSA level . Accurately measuring PSA velocity requires three serial readings, ideally with the same assay, obtained over at least a 12- to 24-month period [65,68,69].
However, analyses of more recent clinical data from randomized trials suggest that PSA velocity adds little predictive information to the total PSA:
●The European Randomized Study of Screening for Prostate Cancer (ERSPC) data from Rotterdam found that PSA velocity was significantly higher in men with prostate cancer than in men with a negative biopsy (0.62 versus 0.46 ng/mL/year) . However, PSA velocity did not independently predict cancer after adjusting for PSA level.
Another analysis of pooled ERSPC data from the Netherlands and Sweden similarly found that PSA velocity only slightly improved the predictive accuracy of total PSA (area under the ROC curve 0.57 versus 0.53) for detecting prostate cancer, but not for detecting high-grade disease .
Among the 774 Rotterdam men with a PSA level below 4.0 ng/mL who underwent their first biopsies in the second round of ERSPC, 149 were found to have cancer . PSA velocity did not discriminate between men with cancer and those with negative biopsies. The sensitivity of a PSA velocity cutoff of 0.3 ng/mL/year was only 39 percent, with a false positive rate of 33 percent.
●In two separate analyses, the Prostate Cancer Prevention Trial reported on the 5519 men from the placebo group who underwent prostate biopsy following at least two PSA measurements in the preceding two or three years [73,74]. While PSA level was a significant predictor of prostate cancer diagnosis on multivariate modeling, incorporating PSA velocity did not add clinically important predictive information to PSA level alone, particularly for PSA values ≥4.0 ng/mL. When total PSA was less than 4.0 ng/mL and the DRE was normal, a PSA velocity above 0.35 ng/mL/year predicted cancer. However, using velocity would substantially increase the number of unnecessary biopsies while missing more high-grade cancers than would be identified by just lowering the PSA cutoff.
●A systematic review of PSA velocity, including 12 comparisons with total PSA for predicting prostate cancer diagnosis, found numerous methodological limitations and essentially no evidence supporting the use of PSA velocity for clinical decision-making .
Some investigators have argued that PSA doubling time or percent change is a more appropriate measure of PSA kinetics . PSA velocity is correlated with the total PSA level, which increases exponentially before clinical diagnosis.
Even though PSA velocity may be independently correlated with cancer diagnosis, it adds little to the diagnostic accuracy of PSA alone .
PSA density — The PSA density measurement is based upon the observation that prostate cancers can produce approximately 10 times more PSA per volume of prostate tissue than benign conditions [19,78]. PSA density measurements, which adjust PSA values for prostate volume, have been reported to better discriminate between cancer and noncancer groups than PSA levels alone .
However, PSA density measurements require transrectal ultrasound or magnetic resonance imaging to assess prostate volume, which limits applicability in primary care settings. Additionally, precisely estimating prostate volume is difficult .
Data from a large multicenter screening trial suggested that using a cutoff PSA density of 0.15 ng/mL/cm3 (a commonly-recommended cutoff value) would miss nearly 50 percent of cancers detected in men with a normal digital rectal examination and PSA levels between 4.0 to 10.0 ng/mL . Adjusting the PSA density cutoff value for total PSA level might improve the test sensitivity .
Free PSA — The observation that PSA exists in a free form as well as bound to macromolecules has been used to develop additional assays to improve test specificity. The ratio of free-to-total PSA is reduced in men with prostate cancer. Investigators have proposed that biopsies be performed only in men with lower ratios. A large multicenter, prospective trial evaluated men 50 to 75 years with PSA levels between 4.0 and 10.0 ng/mL, including 379 with prostate cancer and 394 with benign prostate disease . The cancer detection rate for this PSA range in screening populations is about 25 percent . However, the detection rate increased to 56 percent for men with a free-to-total PSA ratio less than 10 percent . The investigators selected an optimal cutoff of 25 percent as a criterion for biopsy, which would have reduced the number of unnecessary biopsies by 20 percent in their study cohort. However, men with a normal free-to-total PSA ratio still had an 8 percent probability of having cancer, which may not be low enough to convince patients and clinicians to forego biopsy. A meta-analysis came to similar conclusions that free-to-total PSA ratio is generally only clinically helpful at extreme values of the ratio .
A separate meta-analysis of free PSA noted considerable variability in free PSA assays, specimen handling, cutoffs, and patient populations . The authors concluded that more research was necessary to determine the optimal cutoff and to accurately assess the diagnostic performance and utility of the test in screening populations.
Complexed PSA — Another strategy to improve PSA specificity has been to measure complexed PSA (cPSA). Most circulating PSA is bound to alpha-1-antichymotripsin. A study using archival serum found that, at 95 percent sensitivity, cPSA had a specificity of 26.7 percent compared with 15.6 percent for the free-to-total PSA ratio and 21.8 percent for total PSA .
A prospective study in 831 men undergoing prostate biopsy found that cPSA was more specific than total PSA . For men with a total PSA concentration between 4 to 10 ng/mL, when a cPSA cutpoint was chosen to achieve a sensitivity of 90 percent, cPSA had a higher specificity than total PSA (13.3 versus 8.6 percent), but it was less specific than percent free PSA and percent complexed PSA (21.5 and 21.9 percent, respectively). For men with a total PSA concentration between 2 to 6 ng/mL, cPSA was more specific than other methods.
The marginal benefit of measuring complexed PSA over total PSA remains uncertain.
[-2]ProPSA — [-2]ProPSA (also known as p2PSA) is a specific isoform of the PSA proenzyme proPSA. It has been used to increase the detection of prostate cancer for men with PSA values between 2.0 to 10.0 ng/mL. One prospective observational study estimated that using the p2PSA assay could reduce the number of unnecessary biopsies by 7.6 percent while maintaining a sensitivity of 95 percent for detecting prostate cancer . The cohort included 892 men with normal digital rectal examinations, some of whom previously had negative prostate biopsies. Another prospective study of 268 subjects, using the ratio of p2PSA over free PSA, estimated about a 35 percent reduction in the number of unnecessary biopsies while maintaining 95 percent sensitivity . Neither study presented data on the performance of p2PSA for detecting high-risk cancers. The clinical utility of this biomarker is uncertain .
Age-specific reference ranges — PSA levels increase with age, largely due to a higher prevalence of benign prostatic hyperplasia . Although we do not recommend their use, age-specific reference ranges have been developed from normal populations to improve the discriminating power of PSA :
●40 to 49 years — 0 to 2.5 ng/mL
●50 to 59 years — 0 to 3.5 ng/mL
●60 to 69 years — 0 to 4.5 ng/mL
●70 to 79 years — 0 to 6.5 ng/mL
Raising the PSA biopsy threshold in older men improves specificity, reducing the number of unnecessary biopsies. Conversely, lowering the threshold in younger men improves sensitivity and increases detection of early-stage tumors.
A retrospective analysis of a large screening cohort reported that applying age-specific reference standards would miss 47 percent of clinically localized cancers in men 70 and older and lead to a 45 percent increase in unnecessary biopsies for men in their 50s .
The clinical utility of age-specific reference ranges remains uncertain, and they are not recommended by the US Food and Drug Administration (FDA) or PSA assay manufacturers .
Race-specific reference ranges — Black men in the United States have the world's highest incidence of prostate cancer and are the most likely to present with advanced stage disease . PSA levels in blacks are higher compared with whites even after adjusting for age, clinical stage, and histology . This difference has been attributed to blacks having larger tumor volumes across all clinical stages.
Although we do not recommend their use, race-specific PSA reference ranges have been established in the hope of achieving earlier diagnosis :
●40 to 49 years — 0 to 2.5 ng/mL (whites); 0 to 2.0 ng/mL (blacks)
●50 to 59 years — 0 to 3.5 ng/mL (whites); 0 to 4.0 ng/mL (blacks)
●60 to 69 years — 0 to 3.5 ng/mL (whites); 0 to 4.5 ng/mL (blacks)
●70 to 79 years — 0 to 3.5 ng/mL (whites); 0 to 5.5 ng/mL (blacks)
However, a study of 651 men undergoing radical prostatectomy found that the race-specific reference ranges, which raise the cutoff for blacks 50 years and older compared with whites, would be associated with similar or worse outcomes . The clinical utility of the race-specific reference ranges, which have also been developed for Asians , remains uncertain.
Summary — There is no consensus on using any of the PSA modifications, and none of them has been shown in clinical trials to reduce the number of unnecessary biopsies or improve clinical outcomes. The total PSA cutoff of 4.0 ng/mL has been the most accepted standard because it balances the tradeoff between missing important cancers at a curable stage and avoiding both detection of clinically insignificant disease and subjecting men to unnecessary prostate biopsies [41,58,65]. Ongoing efforts are targeted at identifying new serum markers that will have greater diagnostic accuracy for prostate cancer, particularly for aggressive tumors [65,97]. (See "Measurement of prostate specific antigen".)
DIGITAL RECTAL EXAMINATION — We suggest not performing digital rectal examination (DRE) for prostate cancer screening whether alone or in combination with PSA screening. (See 'Combining PSA and DRE' below.) DRE has long been used to diagnose prostate cancer. Abnormal prostate findings include nodules, asymmetry, or induration. DRE can detect tumors in the posterior and lateral aspects of the prostate gland; an inherent limitation to the digital examination is that only 85 percent of cancers arise peripherally where they can be detected with a finger examination . Stage T1 cancers are nonpalpable by definition.
No controlled studies have shown a reduction in the morbidity or mortality of prostate cancer when detected by DRE at any age . The majority of cancers detected by digital examination alone are clinically or pathologically advanced .
DRE is also not recommended for colorectal cancer screening. (See "Screening for colorectal cancer: Strategies in patients at average risk", section on 'Digital rectal examination'.)
Test performance — Urologists have been found to have relatively low interrater agreement for detecting prostate abnormalities . No data are available for the test performance characteristics of DRE in primary care.
Approximately 2 to 3 percent of men 50 or more years old who undergo a single DRE have induration, marked asymmetry, or nodularity of the prostate. In one analysis, an abnormal screening DRE doubled the odds of detecting a clinically important cancer (defined as a having a tumor volume greater than 0.5 mL) that was confined to the prostate . Although screening DRE increased the odds likelihood of finding early disease, it was also associated with a three- to nine-fold increase in the odds of finding extraprostatic extension of tumor (presumably not amenable to curative therapy).
Sensitivity and specificity — A meta-analysis of DRE estimated a sensitivity for detecting prostate cancer of 59 percent and a specificity of 94 percent .
Positive predictive value — The positive predictive value of an abnormal DRE for prostate cancer varies from 5 to 30 percent [48,100,103-106]. A meta-analysis calculated an overall positive predictive value of 28 percent .
COMBINING PSA AND DRE — We suggest not performing digital rectal examination (DRE) for prostate cancer screening whether alone or in combination with PSA screening. PSA and DRE are somewhat complementary, and their combined use can increase the overall rate of cancer detection [41,48,107-109]. As an example, a multicenter screening study of 6630 men reported a detection rate of 3.2 percent for DRE, 4.6 percent for PSA, and 5.8 percent for the two methods combined [48,104]. PSA detected significantly more of the cancers than digital examination (82 versus 55 percent). Overall, 45 percent of the cancers were detected only by PSA, while just 18 percent were detected solely by digital examination.
Investigators reported a positive predictive value of 10 percent for a suspicious digital examination when the PSA level was normal. However, the positive predictive value was 24 percent for an elevated PSA level with a normal digital examination. Among men with a normal PSA level, abnormalities on DRE appear less likely to be from a cancer if the PSA concentration is below 1.0 ng/mL than if the PSA concentration is between 3.0 to 4.0 ng/mL .
Although these data suggest a potential benefit for combining PSA and DRE in detecting prostate cancer, randomized trials have not confirmed a benefit on prostate cancer outcomes. The ERSPC, which found a small survival benefit with PSA screening, did not consistently require DRE . The PLCO found no survival benefit with combined PSA and DRE screening .
PCA3 — The prostate cancer antigen 3 gene (PCA3), which was identified in 1999, is highly overexpressed in almost all prostate cancer tissue specimens, but not in normal or hypertrophied tissue . A PCA3 score, based on the ratio of PCA3 mRNA over PSA mRNA (which is not related to serum PSA levels or cancer), can be determined from a urine specimen collected after a vigorous digital rectal examination. PCA3 has been evaluated for guiding biopsy decisions when PSA levels are in an indeterminate range (2.5 to 10.0 ng/mL) and for men with previously negative biopsies but persistently elevated PSA levels.
A 2010 review identified 11 clinical trials, representing 2737 subjects, evaluating the diagnostic performance of PCA3 :
●In four studies evaluating patients with indeterminate PSA, sensitivity ranged from 53 to 84 percent and specificity ranged from 71 to 80 percent.
●In three studies with at least 200 patients that provided data on PCA3 performance following a previous negative biopsy, sensitivity ranged from 47 to 58 percent, and specificity ranged from 71 to 72 percent. PCA3 outperformed PSA and percent free PSA in independently predicting a positive biopsy.
However, determining the clinical utility of PCA3 from these studies is difficult. Aside from the relatively small sample sizes, studies differed in their criteria for biopsy referral (PSA levels 2.5 to 3.0 ng/mL, digital rectal examination findings, or risk factors), the generation of the PCA3 test used, and the cutpoint for defining an abnormal test. Additionally, none of the studies used PCA3 scores as an indication for biopsy.
The Rotterdam site of the ERSPC subsequently reported the results of using PCA3 as an initial screening test, with sextant biopsy performed if either the PSA level was ≥3 or the PCA3 score was ≥10 . Based on receiver operating characteristic (ROC) curve analysis of 721 subjects undergoing biopsy, PCA3 performed only marginally better than total PSA (area under the curve 0.64 versus 0.58, p = 0.14); PCA3 also missed the majority of cancers with Gleason >6 or stage ≥T2a, though only 19 men met these criteria. However, the generalizability of these results is uncertain because all subjects had already undergone three rounds of screening, and 29 percent had previous negative biopsies.
While PCA3 may eventually have a role in reducing unnecessary biopsies, there are insufficient data on clinical outcomes to currently support routine use .
Transrectal ultrasonography — Transrectal ultrasonography (TRUS) is an outpatient procedure that requires no sedation or analgesia and is relatively well tolerated by most men.
TRUS is not recommended as a primary screening test for prostate cancer because of its low sensitivity and positive predictive value. As an example, in one study almost 40 percent of cancers would have been missed if prostate biopsies had been performed only in men with suspicious findings on TRUS . Furthermore, TRUS is not a feasible screening test in primary care clinics. TRUS is typically used to guide prostate biopsy rather than as a screening test.
EFFECTIVENESS OF PROSTATE CANCER SCREENING — Apart from issues of cost and acceptability, in order for prostate cancer screening to be valuable, it must reduce disease-specific morbidity and/or mortality.
Evidence from randomized trials — Two well-designed large randomized trials have evaluated the effectiveness of screening for prostate cancer and found somewhat differing results:
●In the European Randomized Study of Screening for Prostate Cancer (ERSPC), 182,160 men between the ages of 50 and 74 were randomly assigned to PSA screening (an average of once every four years) or a control group that was not offered screening . This study used different recruiting and randomization procedures across seven centers in Europe. The study used PSA cutoffs between 2.5 and 4.0 ng/mL (most centers used a cutoff of 3.0 ng/mL) as indications for referral for biopsy, variably supplemented with DRE, transrectal ultrasonography, and/or measurements of free PSA levels. The overall rate of prostate cancer screening in the control group was not reported, though 31 percent of cancers were categorized as stage T1c (diagnosed based on elevated PSA level). Investigators subsequently reported PSA testing among 24 percent of the Rotterdam site controls and estimated that 50 percent of the tests were for screening .
With follow-up truncated at 13 years for the 162,243 men in a prespecified core group between the ages of 55 and 69, the primary outcome of prostate cancer mortality was 21 percent lower in the group offered screening (rate ratio 0.79, 95% CI 0.69-0.91) . The absolute rates of prostate cancer mortality were 0.43 versus 0.54 per 1000 person-years (absolute rate difference of 0.11 fewer deaths per 1000 person-years; 781 (95% CI 490-1929) men needed to be invited for screening to prevent one prostate cancer death over 13 years). Prostate cancer was diagnosed more frequently in the screening group (9.6 versus 6.2 cases per 1000 person-years), such that 27 additional cases of prostate cancer would need to be detected by screening to prevent one death from prostate cancer after 13 years. All-cause mortality in the core group was not reduced with screening (18.6 versus 18.9 deaths per 1000 person-years; rate ratio 1.00, CI 0.98-1.02). Prostate cancer mortality was also reduced in the entire cohort of men ages 50 to 74 (rate ratio 0.83, CI 0.73-0.94).
Although the absolute mortality benefit for screening was low, several factors could have biased the results toward no effect. About 24 percent of subjects invited for screening did not undergo PSA testing . While not definitively characterized, a substantial proportion of the control group likely received PSA testing (31 percent of cancers were screening-detected). A subsequent analysis of the Rotterdam site data used patient surveys and linkages with a central national laboratory to estimate contamination. Adjusting for contamination and non-adherence with screening, investigators estimated that prostate cancer screening could reduce prostate cancer mortality by as much as 31 percent (95% CI 8-49 percent) . Additionally, at least 25 percent of cancers detected in the screening group did not receive curative treatment with either surgery or radiation. Finally, given the indolent course of prostate cancer and the five to ten year lead time associated with PSA testing, follow-up duration may have been insufficient to accurately estimate the survival benefit. However, the absolute rate difference has dropped only from 0.06 fewer prostate cancer deaths per 1,000 person-years after nine years of follow-up to the 13-year rate of 0.11 fewer deaths per 1,000 person-years . Furthermore, while the prostate cancer survival benefit from screening was not initially realized until nine years of follow-up , the burdens of screening and treatment, including harms from overdiagnosis and overtreatment, occur immediately and potentially have lifelong consequences.
Several biases could also have favored the screening group . A higher proportion of high-risk cancers diagnosed in the screening group were aggressively treated (surgery or radiation) compared to the control group, so some of the outcome differences could be related more to improved treatment than screening . Among Rotterdam Site men treated with radical prostatectomy, those in the screening group were less likely than those in the control group to experience biochemical recurrence (hazard ratio [HR] 0.43, 95% CI 0.23-0.83), and metastasis (HR 0.18, CI 0.06-0.59); prostate cancer mortality was also reduced, but the finding was not statistically significant with only 12 men dying from prostate cancer . Additionally, the committee adjudicating cause of death was aware of cancer treatments. Previous studies have suggested that cause of death is less likely to be attributed to prostate cancer for patients who received aggressive treatment . The ERSPC investigators did not report the association of receipt of treatment and cancer death.
●The Göteborg, Sweden Randomized Population-based Prostate Cancer Screening Trial, many of whose subjects were also ERSPC participants, reported a rate ratio of 0.56, 95% CI 0.39-0.82 for prostate cancer mortality among screened versus control subjects at a median follow-up of 14 years . In 2014, investigators reported 18-year follow-up data for what they called a study of “organized” PSA screening compared to “opportunistic testing” . Cumulative prostate cancer mortality rates were still lower in the screening group than in the control group (0.98 percent versus 1.5 percent, reflecting 43 fewer deaths). The Göteborg study, which used population registries to randomly allocate men to either the screening or control groups, could plausibly be more likely to demonstrate benefit than the other ERSPC sites because it offered screening every two years (versus every four years). Additionally, the Göteborg results were based on a cohort of men ages 50 to 64, compared with ages 55 to 69 in the combined ERSPC report. This suggests that screening may be less beneficial for men 65 and older, consistent with the finding that radical prostatectomy did not confer a survival benefit compared with watchful waiting for men in this age range . However, experts have questioned these explanations because mortality rates among younger ERSCP subjects were very low, as was the rate of interval cancers . The Goteborg finding could also be due to chance; the 95% CI for the rate ratio overlapped the 0.79 rate ratio reported by ERSPC. Finally, men in the screening group were more likely to receive attempted curative therapy than those in the control group, particularly radical prostatectomy.
●In the United States Prostate, Lung, Colorectal and Ovarian Cancer (PLCO) Screening Trial, 76,693 men between the ages of 55 and 74 were randomly assigned to annual screening with PSA and DRE or to usual care . A PSA level above 4.0 ng/mL or an abnormal DRE were indications for biopsy. A high proportion of men in the control group underwent PSA testing (52 percent in the sixth year of the study) and over 40 percent of study subjects had undergone PSA testing within three years before enrolling in the trial.
In contrast to the ERSPC, after seven years of follow-up there was no reduction in the primary outcome of prostate cancer mortality (50 versus 44 deaths in the screening and control groups, respectively; rate ratio 1.13, 95% CI 0.75-1.70). Cancer detection in the screening group was significantly higher than in the control group (2820 versus 2322, rate ratio 1.22, CI 1.16-1.29). A subsequent publication looking at longer-term follow-up within the PLCO (92 percent follow-up through 10 years; 57 percent through 13 years) found similar prostate cancer mortality results (RR 1.12, CI 1.07-1.17) with no suggestion of reduced mortality in the patients followed for 13 years (RR 1.09, CI 0.87-1.36) . This suggests that the differences in results between the ERSPC and the PLCO were not related to the duration of follow-up. Additionally, the investigators found no evidence that screening could be beneficial in any subgroups defined by comorbidity, age, or pretrial PSA testing.
The negative results could be attributable to the high rate of PSA testing in the control arm, the high proportion of subjects with recent PSA testing at baseline (because serial testing is associated with finding fewer and less aggressive cancers), the higher PSA cutoff for biopsy compared with that used in the ERSPC, or the small number of prostate cancer deaths. An earlier PLCO publication also indicated that substantial proportions of men with abnormal PSA and/or DRE results had not undergone biopsy within three years following the positive screen . All of these factors could bias the PLCO trial toward a null result, and also suggest that further follow-up is not likely to yield positive results.
A 2010 meta-analysis summarized results from six randomized trials (including unique data from two ERSPC sites), with a total of 387,286 participants . Screening with PSA with or without DRE compared to no screening did not reduce death from prostate cancer (relative risk [RR] 0.88, 95% CI 0.71-1.09). However, screening significantly increased the probability of cancer diagnosis (RR 1.46, CI 1.21-1.77). In a 2011 Cochrane meta-analysis that had similar findings, the estimated prostate cancer-specific mortality difference was not statistically significant (RR 0.95, 95% CI 0.85-1.07), but cancer was diagnosed significantly more often in men randomized to screening (RR 1.35, 95% CI 1.06-1.72) .
The concerns that ERSPC mortality findings favoring screening could have been due to differential treatment for high-risk cancers between the screening and control arms [117,118,128] have been partially validated by results from the Prostate Cancer Intervention versus Observation Trial (PIVOT) . PIVOT randomly assigned men with localized prostate cancer, the majority of whom had been detected by PSA screening, to either radical prostatectomy or watchful waiting. After a median follow-up of 10 years, men who were assigned to radical prostatectomy had a reduction in prostate cancer mortality that was not statistically significant (5.8 versus 8.4 percent; HR 0.63, 95% CI 0.36-1.09). Subgroup analyses suggested a potentially greater survival benefit for radical prostatectomy among men with PSA values above 10 ng/mL or high-risk tumor characteristics (based on tumor stage, Gleason, PSA) compared with the group as a whole. (See "Radical prostatectomy for localized prostate cancer", section on 'Survival impact of radical prostatectomy'.)
Evidence from observational studies — Before publication of the randomized trials, other data had been cited to support the effectiveness of screening. Given the conflicting results discussed above, observational studies provide information that can fill in some gaps in evidence from the trials.
Over the past decade, Surveillance Epidemiology and End Results (SEER) tumor registry data have shown a significant decline in the incidence of advanced stage disease, potentially consistent with effective screening . Prostate cancer mortality rates, which initially increased following the advent of PSA testing, have now declined to slightly below pre-PSA levels (figure 1) .
These mortality trends, however, are difficult to interpret. Some ecologic data suggest an association between PSA testing and declining mortality rates [131-133]. However, other ecologic studies have shown declining mortality rates even in the absence of intensive screening .
Alternative explanations have been proposed for declining mortality rates. Better primary treatments could reduce mortality rates among men diagnosed with localized cancer. Additionally, the use of androgen deprivation therapy and other chemotherapies for men with advanced-stage cancer could allow men to survive long enough to die from a comorbid condition. (See "Initial management of regionally localized intermediate, high, and very high-risk prostate cancer" and "Overview of the treatment of disseminated prostate cancer".)
Evidence from modeling studies — Simulation models using data from Surveillance Epidemiology and End Results (SEER) registries suggest that PSA screening could account for 45 to 70 percent of the observed decline in prostate cancer mortality rates, mainly by decreasing the incidence of distant stage disease . However, treatment advancements may have also contributed to the declining mortality rates.
The European Randomized Study of Screening for Prostate Cancer (ERSPC) investigators used simulation models based on their data and observational studies reporting quality of life outcomes to project lifetime numbers of cancer diagnoses, treatments, deaths, and quality-adjusted life years gained after PSA screening . Overall, annual screening between ages 55 to 69 would result in nine fewer prostate cancer deaths per 1000 men followed for an entire lifetime, with a total of 73 life-years gained. Investigators projected that 98 men would need to be screened and five cancers detected to prevent one prostate cancer death. However, after adjusting for the adverse effects of screening, PSA screening resulted in a gain of only 56 quality-adjusted life-years, with a 95% confidence interval ranging from 97 life-years gained to 21 life-years lost. An editorialist noted that these results demonstrate that screening decisions are very sensitive to patient preferences for potential future health states .
A study used microsimulation modeling of observational and clinical trial data to try to determine the comparative effectiveness of alternative PSA screening strategies . Outcome measures included the lifetime number of PSA tests, false-positive results, cancer detection, overdiagnosis, prostate cancer deaths, and lives saved. Compared to a reference strategy of annual PSA testing between ages 50 to 74 with a PSA threshold of 4.0 ng/mL for biopsy referral, strategies that stopped screening at an earlier age, widened testing intervals, and/or used age-adjusted PSA biopsy criteria appeared to reduce the number of tests and the risks for false-positive results and overdiagnosis, while increasing the absolute risk of prostate cancer death by only a fraction of one percentage point. Conversely, screening strategies that lowered the starting age and/or PSA threshold for biopsy referral appeared to markedly increase the number of tests and the risks for false-positive results and overdiagnosis, while only marginally decreasing the risk of prostate cancer death. However, concerns were raised about the analyses, including the failure to model risk factors, the use of simplified measures for stage and grade, and not considering patient preferences .
HARM FROM SCREENING
Risks of biopsy — Although early reports indicated that prostate biopsies very rarely (<1 percent) caused complications (eg, bleeding, infection) serious enough to require hospitalization , more recent studies suggest both higher rates of infectious complications and that the rate of infectious complications may be increasing over time [141-144]. Hospitalization rates for infectious complications in these studies have ranged from 0.6 to 4.1 percent .
Infectious complications can lead to sepsis, which can very rarely lead to death. A modeling study, assuming a biopsy mortality rate of 0.2 percent , concluded that prostate cancer screening could be associated with a net increased overall mortality, particularly under the conditions that biopsy rates are high and screening is relatively ineffective . However, other studies have suggested much lower mortality rates following biopsy . Population-based studies include an analysis of US Medicare data that found a mortality rate of 0.3 percent in the 30 days following biopsy; this was actually 70 percent lower than the 30-day mortality in a comparison population not undergoing biopsy . An analysis of registry data from Canada found a 30-day mortality rate of 0.09 percent . Randomized trials with follow-up on 1147 biopsies , and 10,474 biopsies , reported no biopsy-related deaths.
Prostate biopsy can also lead to anxiety and physical discomfort . Among 116 men undergoing biopsy in the Rotterdam screening study, 55 percent reported discomfort with the procedure, including 2 percent who had pain persisting longer than one week.
Being diagnosed with prostate cancer is psychologically distressing, but even patients with a negative biopsy result may be distressed [150,151]. Chronic anxiety can follow a negative prostate biopsy because this apparently favorable result cannot completely rule out prostate cancer given the relatively high false-negative biopsy rate .
Overdiagnosis — Overdiagnosis refers to the detection by screening of conditions that would not have become clinically significant. When screening finds cancer that would never have become clinically significant, patients are subject to the risks of screening, confirmatory diagnosis, and treatment, as well as suffering potential psychosocial harm from anxiety and labeling. Overdiagnosis is of particular concern because most men with screening-detected prostate cancers have early-stage disease and will be offered aggressive treatment.
A number of reports have raised concerns about the risk of overdiagnosis with screening:
●While the lifetime risk of being diagnosed with prostate cancer has increased from 1 in 11 to 1 in 6, the lifetime risk of dying from prostate cancer has remained around 1 in 34 following the advent of PSA testing .
●Although about 80 percent of detected cancers are considered clinically important based on tumor size and grade , these are relatively crude prognostic markers. Autopsy series in men who died from other causes have shown a 30 to 45 percent prevalence of prostate cancer in men in their fifties and an 80 percent prevalence in men in their seventies [154-156].
●A study that applied computer-simulation models of PSA testing to SEER cancer incidence data estimated that 29 percent of cancers detected in whites and 44 percent of cancers detected in blacks were overdiagnosed . An updated analysis, that also used ERSPC Rotterdam clinical data, estimated an overdiagnosis fraction ranging from 23 to 42 percent among cancers diagnosed by PSA screening .
●Similarly, a study that applied simulation models to the results of the ERSPC estimated a 50 percent overdetection rate with annual screening for men ages 55 to 67 . Given that the screening group in the ERSPC had a 72 percent higher cumulative incidence of prostate cancer than the control group after 11 years of follow-up (9.6 versus 6.0 percent) , the potential absolute risk for overdiagnosis is substantial.
●A study examined the number of men diagnosed and treated for prostate cancer in the United States (US) each year after 1986, the year before PSA screening was introduced, until 2005 . The study estimated that approximately 1.3 million additional men were diagnosed with prostate cancer as a result of screening, of whom approximately 1 million were treated. Assuming that the entire decline in prostate cancer mortality in the US from 1986 through 2005 was due to screening, an extremely optimistic assumption for PSA screening, approximately 23 men had to be diagnosed and 18 men treated for prostate cancer to prevent one death. The authors concluded that most of the additional cases of prostate cancer found since 1986 represent overdiagnosis.
The risk of overdiagnosis of prostate cancer appears to increase with increasing age .
Risks of therapy — Even in the absence of treatment, many men found to have prostate cancer as a result of screening will have a lengthy period of time without clinical problems. However, undergoing radical prostatectomy and radiation therapies can lead to immediate complications:
●Less serious, but more common complications include urinary incontinence, sexual dysfunction, and bowel problems. Radical prostatectomy can substantially decrease sexual function in 20 to 70 percent of men and lead to urinary problems in 15 to 50 percent [14,165,166].
External beam radiation therapy has been reported to cause erectile dysfunction in 20 to 45 percent of men with previously normal erectile function, urinary incontinence in 2 to 16 percent of previously continent men, and bowel dysfunction in 6 to 25 percent of men with previously normal bowel function [14,165,167].
Given the ERSPC study estimate that 27 men need to be diagnosed with prostate cancer (of whom at least 60 percent received surgery or radiation) to prevent one prostate cancer death during 13 years of follow-up, the quality of life issues related to treatment selection are very important decision-making factors.
APPROACH TO SCREENING — Although screening for prostate cancer with PSA can reduce mortality from prostate cancer, the absolute risk reduction is very small. Given limitations in the design and reporting of the randomized trials, there remain important concerns about whether the benefits of screening outweigh the potential harms to quality of life, including the substantial risks for overdiagnosis and treatment complications. Men who are willing to accept a substantial risk of morbidity associated with treatment in return for a small reduction in mortality might reasonably choose to be screened. Men who are at increased risk of prostate cancer because of race or family history may be more likely to benefit from screening.
Informed decision making — Given the important tradeoffs between potential benefits and harms involved with either screening or not screening for prostate cancer, and the lack of definitive data on screening outcomes, it is particularly important that patients make informed decisions about undergoing testing [124,128,168-170].
The United States Preventive Services Task Force Guidelines , American College of Physicians , American Urologic Association , American Cancer Society , and the Canadian Task Force on the Periodic Health Examination  all stress the importance of informed decision making.
The American College of Physicians and the American Cancer Society have provided useful summaries of discussion points to consider when counseling patients about prostate cancer screening [46,172,175]:
●Prostate cancer is an important health problem; it is one of the most frequently diagnosed cancers in the United States and a leading cause of cancer death in men.
●Prostate cancer screening is controversial, and men should be involved in making the decision whether or not to be screened.
●Prostate cancer screening may reduce the chance of dying from prostate cancer. However, the evidence is mixed and the absolute benefit is small. For most men, the chances of harm from PSA screening outweigh the benefits.
●Most men who choose not to have PSA testing will not be diagnosed with prostate cancer and will die from some other cause.
●In order to determine whether a cancer is causing an abnormal test, men need to undergo a prostate biopsy. However, the PSA test and digital rectal exam (DRE) can both have false-positive and false-negative results. Prostate biopsies may also miss finding cancers and can rarely cause serious infections.
●Patients who choose PSA testing are much more likely than those who decline PSA testing to be diagnosed with prostate cancer. Many cancers detected by screening are considered "overdiagnosed", meaning that they never would have caused problems during a man's lifetime.
●No current tests can accurately determine which men with a cancer found by screening are most likely to benefit from aggressive treatment (ie, those whose cancers are destined to cause health problems). Most men with prostate cancer will die from other causes; many will never experience health problems from their cancer.
●Aggressive therapy is necessary to realize any benefit from finding an early-stage prostate cancer, however, studies show that only men with high PSA or Gleason score are likely to benefit.
●Surgery and radiation therapies are the treatments most commonly offered in an attempt to cure prostate cancer; however, they can lead to problems with urinary, bowel, and sexual function.
●A strategy of active surveillance may be appropriate for men who are at low risk for complications from prostate cancer (PSA <10 ng/mL and Gleason <7). This means not immediately treating a cancer but following PSA tests, DRE, and repeating biopsies to determine whether aggressive treatment is indicated because the cancer is progressing .
Clinicians find it challenging to provide comprehensive, consistent, and balanced information about prostate cancer screening decisions during clinic visits [12,177]. Consequently, efforts have focused on using decision support tools to help patients understand screening issues and make informed decisions for screening [178,179].
Investigators have evaluated a number of interventions to facilitate such informed prostate cancer screening decisions including videotapes [180-182], patient group discussions , brief scripts read to patients during clinic visits , verbal and written material provided before a periodic health examination , and informational pamphlets distributed at study visits  or through the mail .
Current websites providing decision support tools include:
The content of a screening discussion or the provision of a decision aid should be documented in the medical record, particularly when the patient decides against screening.
A systematic review of 18 trials of patient decision aids for prostate cancer screening found that decision aids consistently improved patient knowledge about prostate cancer and screening, increased participation in decision making, and made patients more confident about their decisions . Receiving a decision aid generally decreased intention to be screened and resulted in lower screening rates among patients coming for routine office visits (relative risk 0.88, 95% CI 0.81-0.97). Similarly, in a subsequent large randomized trial, decision aids increased patient knowledge and decisional satisfaction and decreased decisional conflict, however, they had no effect on actual rates of screening .
Age to begin screening — Screening should be discussed with average-risk men beginning at age 50, though not with men who have a comorbidity that limits their life expectancy to less than 10 years [41,46].
We suggest that providers first discuss screening with men at high risk for prostate cancer, including black men, men with a family history of prostate cancer, particularly in relatives younger than age 65, and men who are known or likely to have the BRCA1 or BRCA2 mutations, beginning at age 40 to 45 [46,189-191]. Men who are at increased risk of prostate cancer because of race or family history may be more likely to benefit from screening, however there is relatively little evidence addressing this and these men should be informed that the potential benefits and risks of early screening are uncertain. (See "Risk factors for prostate cancer", section on 'Genetic factors'.)
Others, including other authors for UpToDate, suggest not initiating screening discussions earlier in higher risk men, given that age is a primary determinant of risk and earlier discussions may increase the risk of harms related to screening. (See "Preventive care in adults: Recommendations", section on 'Prostate cancer'.)
Frequency and method of screening — When a decision is made to screen for prostate cancer, the recommended strategy has been to perform a digital examination and measure a PSA level [41,46]. However, the randomized ERSPC found that PSA screening alone, measured at a median interval of four years (range two to seven years), resulted in a significant, though small, reduction in prostate cancer mortality . The PLCO study, which screened with annual PSA and DRE, found no reduction in mortality . The optimal interval and combination of tests remains uncertain, however based on current data we suggest screening every two to four years with PSA alone.
An analysis from the ERSPC compared outcomes from two centers with different screening intervals, Gothenburg (2 years; n = 4202) and Rotterdam (4 years; n = 13,301) . The 10-year incidence of prostate cancer was significantly higher in the center with the shorter screening interval (13.1 versus 8.4 percent). Aggressive interval cancers were uncommon, and cumulative rates of such cancers were similar in the two centers (0.11 versus 0.12 percent, respectively). Follow-up was not long enough to compare mortality rates. There were potentially important differences between the patients and screening methods at these two centers that limit the strength of this nonrandomized comparison of screening intervals.
One study that applied modeling to identify an optimal PSA testing strategy concluded that the most efficient strategy would be to screen men at age 40 and 45 years and then every two years from ages 50 to 75, while still using the 4.0 ng/mL cutoff as a criterion for biopsy referral .
Studies have also raised the possibility of less frequent retesting in men with lower initial PSA levels (eg, ≤1.0, 1.5. or 2.0 ng/mL), while still testing annually in those with higher PSA levels (but still below a cutoff for biopsy) [194-196]:
●The Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial found that only 1.5 percent (95% CI 1.2-1.7) of men with an initial PSA less than 1 ng/mL converted to a PSA greater than 4.0 ng/mL after five years . The report estimated that only 0.12 percent of men with an initial PSA less than 1 ng/mL would be diagnosed with prostate cancer during a five-year interval. The initial PSA level was not correlated with conversion to an abnormal digital rectal examination (DRE); conversion within three years of baseline screening was nearly 10 percent, even for men with an initial PSA level below 1 ng/mL.
●Similar findings for PSA screening were noted in the European Randomized Study of Screening for Prostate Cancer (ERSPC) in which the proportion of men with a baseline PSA below 1.0 ng/mL who converted to a level above 3.0 ng/mL was 0.9 percent after four years . The estimated cancer detection rate was 0.15 percent during a four-year interval.
In the PLCO trial, a four-year screening interval in men with a PSA below 1.0 ng/mL was estimated to result in a delay in cancer diagnosis of 15.6 months . A separate report came to a similar estimate . The clinical consequences of delayed diagnosis on prostate cancer mortality and morbidity are unknown, although the majority of cancers detected after a four-year screening interval in the ERSPC were early-stage .
Referrals for biopsy — If digital rectal exam is performed, either for screening or for symptoms, men with abnormal prostate exams (nodules, induration, or asymmetry) should be referred to an interventional specialist who can evaluate them for a transrectal ultrasound-guided prostate biopsy.
Men with abnormal PSA values can also be referred, although some experts recommend first repeating the PSA several weeks later, particularly for borderline elevations below 7.0 ng/mL [59,68]. We suggest that primary care providers refer men with a PSA level above 7 ng/mL without further testing; the interventional specialist can decide whether to proceed directly to biopsy or perform additional testing.
We suggest that men with a PSA level between 4 ng/mL and 7 ng/mL undergo repeat testing several weeks later. Before repeating PSA testing, men should abstain from ejaculation and bike riding for at least 48 hours. Men with symptomatic prostatitis should be treated with antibiotics before retesting. Men with a repeat PSA level above 4 ng/mL should be referred for biopsy.
One reason to repeat PSA testing in men with borderline elevations is that PSA measurements have considerable short-term variability [67,198]. A retrospective analysis of stored serum from 972 men found substantial year-to-year fluctuations with 44 percent of men with a PSA above 4.0 ng/mL having normal PSA findings at subsequent annual visits . In addition to biological variability, PSA may be transiently elevated due to ejaculation, perineal trauma, or prostatitis. (See "Acute bacterial prostatitis".)
Although the ERSPC used lower PSA ranges (2.5 to 3.0 ng/mL), test results were used in conjunction with various ancillary tests (DRE, transrectal ultrasonography) to guide biopsy referrals . The total PSA cutoff of 4.0 ng/mL has been the most accepted standard because it balances the tradeoff between missing important cancers at a curable stage and avoiding both detection of clinically insignificant disease and subjecting men to unnecessary prostate biopsies [35,61,65,138]. We suggest that a PSA level of 4.0 ng/mL be considered abnormal in determining who should be referred for biopsy.
Biopsy referrals may also be based upon PSA velocity, PSA density, measurements of free or complexed PSA, and age- and race-specific PSA levels, although the clinical utility of these modifications is uncertain, and we do not recommend them for determining who should be referred for biopsy. Retrospective analyses of data from the ERSPC suggest that the predictive value of PSA for detecting cancer is not improved by incorporating PSA velocity data [70-72].
Attempts have been made to create risk models for prostate cancer based on multiple variables (eg, PSA, age, family history, DRE result, prostate volume, previous negative biopsies, PSA velocity, free PSA, etc.). A meta-analysis concluded that some models improved the predictive value of PSA for detecting prostate cancer, with areas under the curve (AUC) ranging from 0.66-0.79 . Only one model was used to predict clinically-significant (high-grade) cancer, with an overall AUC 0.71 (95% CI 0.67-0.75); however, estimates showed a high degree of heterogeneity. Until such models have undergone additional study for clinical effectiveness, we do not recommend using them to decide who should undergo biopsy.
Repeat biopsies — If a biopsy is positive, the cancer will be staged, and the patient will be presented with treatment options. AUA guidelines recommend that patients should resume routine screening if the biopsy is negative . However, given the potential for false-negative results, some investigators have recommended repeating the biopsies.
A study that repeated 100 negative sextant biopsies found cancer in 20 percent . Among five men with high-grade PIN at initial biopsy, all had carcinoma detected on repeat biopsy, as did 5 of 17 (29.4 percent) of men with atypia; only 10 of 69 (14.5 percent) men without PIN or atypia had cancer detected. PSA levels above 20 ng/mL also predict positive repeat prostate biopsies .
In a study of serial biopsies in 1051 Austrian and Belgian participants in the European Prostate Cancer Detection study with PSA levels between 4.0 to 10.0 ng/mL, cancer was detected in 83 of 820 (10 percent) men with BPH who underwent repeat biopsy six weeks after a negative biopsy . A percent free PSA less than 30 percent and a PSA density greater than 0.26 ng/mL/cc were the most accurate predictors of cancer detection with areas under the ROC curves of 74.5 and 61.8 percent, respectively. Cancer was detected in 5 percent of men undergoing a third biopsy and 4 percent of men undergoing a fourth biopsy. However, tumors detected with these biopsies were significantly smaller and better differentiated than tumors found with the first two biopsies. The authors concluded that repeating one biopsy was justified .
In contrast, 272 men in the screening arm of the ERSPC, Rotterdam had a PSA ≥4.0 ng/mL and a negative biopsy and underwent repeat screening four years later . In 217 of the men with a repeat PSA ≥3.0 ng/mL a biopsy was performed; prostate cancer was found in 18 (positive predictive value 8.3 percent). The majority (88.5 percent) of cancers detected during the second round of screening were organ confined, and the authors concluded that there was no need for immediate repeat biopsies in men with a PSA ≥4.0 ng/mL and a negative initial biopsy.
Another analysis of the ERSPC, Rotterdam data evaluated factors associated with having cancer detected during the second round of screening among men with a previous negative biopsy . Having a previous negative biopsy was the only factor significantly associated with biopsy outcome in the second round of screening. Among 459 men with a previous negative biopsy who underwent a second biopsy because their PSA level was still elevated on the second round of screening, only 48 cancers were detected (positive predictive value 10.5 percent). In comparison, 149 cancers were diagnosed in men with elevated PSA levels who had not been previously biopsied (positive predictive value 25.6 percent). After adjusting for the previous negative biopsy in multivariate models, investigators did not find that either total PSA level (all were above 3.0 ng/mL) or PSA velocity significantly predicted finding cancer on the second biopsy.
We suggest that men with negative extended biopsies (biopsies performed using an extended protocol as opposed to just sextant biopsies) be managed similarly to men who have not previously undergone screening. That is, when screening is next routinely considered, men should again make an informed decision about testing; if the decision is made to screen, the same criteria used for the initial biopsy referral should again be applied. (See "Prostate biopsy".)
Stopping screening — Screening for prostate cancer is unlikely to benefit men with less than a 10-year life expectancy given the generally indolent course of the disease. While most agree with stopping screening of men who develop substantial comorbidities, applying an upper age limit to screening has less of a consensus.
●Actuarial tables suggest that among men in average health, only those ages 75 and younger have a 10-year life expectancy, and guidelines recommend against screening older men.
●An analysis of data from the Baltimore Longitudinal Aging Study found that discontinuing PSA testing at age 65 for men with PSA levels 0.5 ng/mL or less would still identify all cancers that would have been detected by age 75 . If screening were discontinued for men with PSA levels of 1.0 ng/mL or less at age 65, then 94 percent of the cancers would still be detected.
●A case-control study from a population-based cohort in Sweden estimated that a PSA level ≤1 ng/mL at age 60 was associated with an extremely low risk of prostate cancer metastasis (0.5 percent) or death from prostate cancer (0.2 percent) by age 85 .
●A population-based cohort study using SEER-Medicare linked data evaluated outcomes of 89,877 older men (median age 78) diagnosed with clinically localized prostate cancer between 1992 and 2002 who were managed without attempted curative therapy. The 10-year prostate cancer specific mortality ranged from 8.3 percent (95% CI 4.2-12.8 percent) for men with well-differentiated cancers to 25.6 percent (CI 23.7-28.3 percent) for men with poorly-differentiated cancers. Approximately 60 percent of all subjects died from competing causes .
●Another SEER-Medicare analysis highlighted the importance of considering comorbidity. Among men with localized prostate cancer aged 75 and older, the 10-year prostate cancer mortality without attempted curative therapy was only 5.0 percent (CI 2.5-8.7 percent) for those with moderately-differentiated cancers and two or more comorbidities. The 10-year prostate cancer mortality was 18.8 percent (CI 9.3-36.8 percent) for men with poorly-differentiated cancers and two or more comorbidities .
●A decision analysis using Medicare data found that aggressively treating men age 70 and older could actually decrease the quality adjusted life expectancy .
●In contrast, another decision model, using results from the Scandinavian randomized trial of radical prostatectomy versus watchful waiting and case series utilizing three-dimensional conformal external beam radiation, concluded that many healthy men in their 70s or 80s with at least moderate-grade disease would benefit from aggressive therapy. However, subsequent results from the Scandinavian trial suggest that mortality benefits from radical prostatectomy may be limited to men younger than age 65.
Currently, clinical trial data are insufficient to resolve this issue, though the ERSPC initially found a screening survival benefit only among the core group of men ages 55 to 69.
RECOMMENDATIONS OF OTHERS
●The American Cancer Society (ACS) emphasizes the need for involving men in the decision whether to screen for prostate cancer. Men need to have sufficient information regarding the risks and benefits of screening and treatment to make an informed and shared decision; providing them with a decision aid may facilitate the decision-making process . For men who decide to be screened, the ACS recommends PSA testing with or without DRE for average-risk men beginning at 50 years of age. Screening should not be offered to men with a life expectancy less than 10 years. Men whose initial PSA level is greater than or equal to 2.5 ng/mL should undergo annual testing; men with a lower initial level can be tested every two years. The guidelines also recommend beginning screening discussions at age 40 to 45 in patients at high-risk of developing prostate cancer (eg, black men and men with a first-degree relative with prostate cancer diagnosed before age 65). The guideline also recommends keeping the biopsy referral threshold at 4.0 ng/mL. However, for men with PSA levels from 2.5 to 4.0 ng/mL, the guideline encourages individualized decision making and risk assessment (http://deb.uthscsa.edu/URORiskCalc/Pages/uroriskcalc.jsp), which can include age, race, family history, digital rectal examination findings, previous biopsy results, and use of five alpha-reductase inhibitors.
●The American Urological Association (AUA) updated its guideline in 2013 . The AUA recommends against screening men younger than 40, and also does not recommend routine screening for average-risk men ages 40 to 54, men older than 70, or men with a life expectancy of less than 10 to 15 years. Decisions should be individualized for higher-risk men ages 40 to 54, and the AUA noted that some men over age 70 in excellent health might benefit from screening. The AUA strongly recommends shared decision making in deciding on PSA screening in men ages 55 to 69. The guideline panel could find no evidence to support the continued use of DRE as a first-line method of screening. The AUA stated that a screening interval of two years for men who choose screening may be preferred to annual screening and that screening intervals can be individualized based on baseline PSA level. The guideline noted the lack of evidence for using any tests (eg, PSA derivatives, PSA kinetics, PSA molecular markers, urinary markers, imaging, or risk calculators) other than PSA for triggering a biopsy referral. While the AUA did not recommend a specific threshold for biopsy referral, they did suggest using a threshold of 10.0 ng/mL for men 70 years and older.
●The United States Preventive Services Task Force (USPSTF) updated its recommendations in 2012 to recommend that men not be screened for prostate cancer, concluding that there is moderate certainty that the benefits of such screening do not outweigh the harms . The USPSTF did advise that men requesting screening be supported in making an informed decision. The USPSTF clinical practice guideline for screening for prostate cancer, as well as other USPSTF guidelines, can be accessed through the website for the Agency for Healthcare Research and Quality.
●The Canadian Task Force on Preventive Health Care makes strong recommendations against screening for prostate cancer with PSA for men younger than 55 or older than 69, and makes a weak recommendation against screening with PSA for men ages 55 to 69 .
●The United Kingdom National Screening Committee does not recommend screening for prostate cancer .
●The Australian Cancer Council states that the evidence does not support population-based screening and recommends a patient-centered approach that individualizes the decision .
●The European Society for Medical Oncology (ESMO) recommends against population based screening and in favor of an individualized approach using shared decision making . ESMO further states that there is inconsistent evidence on screening men younger than 50 and between 70 and 75 years of age, and evidence that the harms of screening outweigh the benefits for men over age 75.
●The Clinical Guidelines Committee of the American College of Physicians (ACP) produced a “guidance statement” in 2013 based on their rigorous review of guidelines developed by other United States organizations, including the American College of Preventive Medicine, the American Cancer Society, the American Urological Association, and the US Preventive Services Task Force . The ACP guidance statement recommends that clinicians inform men ages 50 to 69 about the limited potential benefits and substantial harms of prostate cancer screening and only screen men who express a clear preference for being screened. The guidance statement also recommends against screening for prostate cancer in average-risk men under the age of 50 and against screening in men over the age of 69 or with a life expectancy less than 10 to 15 years.
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)
●Basics topics (see "Patient information: Prostate cancer screening (PSA tests) (The Basics)")
●Beyond the Basics topics (see "Patient information: Prostate cancer screening (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS — Although screening for prostate cancer with PSA can reduce mortality from prostate cancer, the absolute risk reduction is very small. Given limitations in the design and reporting of the randomized trials, there remain important concerns that the benefits of screening are outweighed by the potential harms to quality of life, including the substantial risks for overdiagnosis and treatment complications. (See 'Approach to screening' above.)
●Because individual patient preferences for specific health outcomes are a deciding factor in determining whether to screen for prostate cancer, men who are potential candidates for screening should be engaged in discussions or decision-making processes that inform them and evoke these preferences:
•Discussions should present men with information on the risks and benefits of screening, such as those in the summary points suggested by the American Cancer Society that are discussed above (see 'Informed decision making' above). Using existing written or video decision aids may help ensure that patients receive consistent, complete, and objective information and may optimize the time spent discussing screening during a clinic visit.
•Health care providers should periodically discuss prostate cancer screening with men who are expected to live at least 10 years and are old enough to be at significant risk for prostate cancer. We suggest that discussions begin at age 50 in average-risk men (Grade 2B). We suggest that discussions begin at age 40 to 45 in men at high risk for prostate cancer, including black men, men with a family history of prostate cancer, particularly in relatives younger than age 65, and men who are known or likely to have the BRCA1 or BRCA2 mutations (Grade 2C). Men who are at increased risk of prostate cancer because of race or family history may be more likely to benefit from screening, however there is relatively little evidence addressing this and these men should be informed that the potential benefits and risks of early screening are uncertain. (See 'Age to begin screening' above.)
●When a decision is made to screen, we suggest that screening be performed with prostate specific antigen (PSA) tests at intervals ranging from every two to four years (Grade 2B). We suggest not performing digital rectal examination as part of screening (Grade 2C). (See 'Frequency and method of screening' above.)
●When a decision is made to screen, we suggest that screening stop after age 69 or earlier when comorbidities limit life expectancy to less than 10 years, or the patient decides against further screening (Grade 2B). Stopping screening at age 65 may be appropriate if the PSA level is less than 1.0 ng/mL. (See 'Stopping screening' above.)
●Men with an abnormal DRE (if performed) or PSA level above 7 ng/mL should be referred, without further testing, to an interventional specialist who can evaluate them for a transrectal ultrasound-guided prostate biopsy. (See 'Referrals for biopsy' above.)
●We suggest that men with a PSA level between 4 ng/mL and 7 ng/mL undergo repeat testing several weeks later (Grade 2C). Prior to repeat PSA testing, men should abstain from ejaculation and bike riding for at least 48 hours. Men with symptomatic prostatitis should be treated with antibiotics before retesting. Men with a repeat PSA level above 4 ng/mL should be referred for transrectal ultrasound-guided prostate biopsy. (See 'Referrals for biopsy' above.)
●We suggest that men with negative extended biopsies (biopsies performed using an extended protocol as opposed to just sextant biopsies) be managed similarly to men who have not previously undergone screening (Grade 2C). That is, when screening is next routinely considered, men should again make an informed decision about testing; if the decision is made to screen, the same criteria used for the initial biopsy referral should again be applied. (See 'Repeat biopsies' above.)
- Siegel RL, Miller KD, Jemal A. Cancer statistics, 2015. CA Cancer J Clin 2015; 65:5.
- Torre LA, Bray F, Siegel RL, et al. Global cancer statistics, 2012. CA Cancer J Clin 2015; 65:87.
- Ries, LAG, Melbert, D, Krapcho, M, et al (Eds). SEER Cancer Statistics Review, 1975-2004, National Cancer Institute, Bethesda, MD 2007. Available at: http://seer.cancer.gov/csr/1975_2004/ (Accessed on October 16, 2009).
- Bell KJ, Del Mar C, Wright G, et al. Prevalence of incidental prostate cancer: A systematic review of autopsy studies. Int J Cancer 2015; 137:1749.
- Mettlin C, Jones G, Averette H, et al. Defining and updating the American Cancer Society guidelines for the cancer-related checkup: prostate and endometrial cancers. CA Cancer J Clin 1993; 43:42.
- American Urological Association. Early detection of prostate cancer and use of transrectal ultrasound. In: American Urological Association 1992 Policy Statement Book, Williams & Wilkins, Baltimore 1992.
- LAG, Eisner, MP, Kosary, CL, et al. SEER Cancer Statistics Review, 1973-1999, National Cancer Institute, Bethesda, MD 2002.
- Lu-Yao GL, Greenberg ER. Changes in prostate cancer incidence and treatment in USA. Lancet 1994; 343:251.
- Lu-Yao GL, Friedman M, Yao SL. Use of radical prostatectomy among Medicare beneficiaries before and after the introduction of prostate specific antigen testing. J Urol 1997; 157:2219.
- Potosky AL, Miller BA, Albertsen PC, Kramer BS. The role of increasing detection in the rising incidence of prostate cancer. JAMA 1995; 273:548.
- Stanford, JL, Stephenson, RA, Coyle, LM, et al. Prostate Cancer Trends 1973-1995, Publication no. 99-4543, SEER Program, National Cancer Institute, Bethesda, MD 1999.
- Brett AS, Ablin RJ. Prostate-cancer screening--what the U.S. Preventive Services Task Force left out. N Engl J Med 2011; 365:1949.
- Schröder FH, Hugosson J, Roobol MJ, et al. Screening and prostate-cancer mortality in a randomized European study. N Engl J Med 2009; 360:1320.
- Wilt TJ, MacDonald R, Rutks I, et al. Systematic review: comparative effectiveness and harms of treatments for clinically localized prostate cancer. Ann Intern Med 2008; 148:435.
- Andriole GL, Crawford ED, Grubb RL 3rd, et al. Mortality results from a randomized prostate-cancer screening trial. N Engl J Med 2009; 360:1310.
- Gann PH, Hennekens CH, Stampfer MJ. A prospective evaluation of plasma prostate-specific antigen for detection of prostatic cancer. JAMA 1995; 273:289.
- Draisma G, Boer R, Otto SJ, et al. Lead times and overdetection due to prostate-specific antigen screening: estimates from the European Randomized Study of Screening for Prostate Cancer. J Natl Cancer Inst 2003; 95:868.
- Whittemore AS, Cirillo PM, Feldman D, Cohn BA. Prostate specific antigen levels in young adulthood predict prostate cancer risk: results from a cohort of Black and White Americans. J Urol 2005; 174:872.
- Stamey TA, Yang N, Hay AR, et al. Prostate-specific antigen as a serum marker for adenocarcinoma of the prostate. N Engl J Med 1987; 317:909.
- Tchetgen MB, Oesterling JE. The effect of prostatitis, urinary retention, ejaculation, and ambulation on the serum prostate-specific antigen concentration. Urol Clin North Am 1997; 24:283.
- Yuan JJ, Coplen DE, Petros JA, et al. Effects of rectal examination, prostatic massage, ultrasonography and needle biopsy on serum prostate specific antigen levels. J Urol 1992; 147:810.
- Nadler RB, Humphrey PA, Smith DS, et al. Effect of inflammation and benign prostatic hyperplasia on elevated serum prostate specific antigen levels. J Urol 1995; 154:407.
- Chybowski FM, Bergstralh EJ, Oesterling JE. The effect of digital rectal examination on the serum prostate specific antigen concentration: results of a randomized study. J Urol 1992; 148:83.
- Effect of digital rectal examination on serum prostate-specific antigen in a primary care setting. The Internal Medicine Clinic Research Consortium. Arch Intern Med 1995; 155:389.
- Herschman JD, Smith DS, Catalona WJ. Effect of ejaculation on serum total and free prostate-specific antigen concentrations. Urology 1997; 50:239.
- Tchetgen MB, Song JT, Strawderman M, et al. Ejaculation increases the serum prostate-specific antigen concentration. Urology 1996; 47:511.
- Kawakami J, Siemens DR, Nickel JC. Prostatitis and prostate cancer: implications for prostate cancer screening. Urology 2004; 64:1075.
- Simardi LH, Tobias-MacHado M, Kappaz GT, et al. Influence of asymptomatic histologic prostatitis on serum prostate-specific antigen: a prospective study. Urology 2004; 64:1098.
- Guess HA, Heyse JF, Gormley GJ. The effect of finasteride on prostate-specific antigen in men with benign prostatic hyperplasia. Prostate 1993; 22:31.
- Roehrborn CG, Marks LS, Fenter T, et al. Efficacy and safety of dutasteride in the four-year treatment of men with benign prostatic hyperplasia. Urology 2004; 63:709.
- Andriole GL, Guess HA, Epstein JI, et al. Treatment with finasteride preserves usefulness of prostate-specific antigen in the detection of prostate cancer: results of a randomized, double-blind, placebo-controlled clinical trial. PLESS Study Group. Proscar Long-term Efficacy and Safety Study. Urology 1998; 52:195.
- Etzioni RD, Howlader N, Shaw PA, et al. Long-term effects of finasteride on prostate specific antigen levels: results from the prostate cancer prevention trial. J Urol 2005; 174:877.
- Andriole GL, Bostwick D, Brawley OW, et al. The effect of dutasteride on the usefulness of prostate specific antigen for the diagnosis of high grade and clinically relevant prostate cancer in men with a previous negative biopsy: results from the REDUCE study. J Urol 2011; 185:126.
- Marberger M, Freedland SJ, Andriole GL, et al. Usefulness of prostate-specific antigen (PSA) rise as a marker of prostate cancer in men treated with dutasteride: lessons from the REDUCE study. BJU Int 2012; 109:1162.
- Punglia RS, D'Amico AV, Catalona WJ, et al. Effect of verification bias on screening for prostate cancer by measurement of prostate-specific antigen. N Engl J Med 2003; 349:335.
- Stroumbakis N, Cookson MS, Reuter VE, Fair WR. Clinical significance of repeat sextant biopsies in prostate cancer patients. Urology 1997; 49:113.
- Ellis WJ, Brawer MK. Repeat prostate needle biopsy: who needs it? J Urol 1995; 153:1496.
- Levine MA, Ittman M, Melamed J, Lepor H. Two consecutive sets of transrectal ultrasound guided sextant biopsies of the prostate for the detection of prostate cancer. J Urol 1998; 159:471.
- Eichler K, Hempel S, Wilby J, et al. Diagnostic value of systematic biopsy methods in the investigation of prostate cancer: a systematic review. J Urol 2006; 175:1605.
- McNaughton Collins M, Ransohoff DF, Barry MJ. Early detection of prostate cancer. Serendipity strikes again. JAMA 1997; 278:1516.
- Carroll P, Coley C, McLeod D, et al. Prostate-specific antigen best practice policy--part I: early detection and diagnosis of prostate cancer. Urology 2001; 57:217.
- Brawer MK, Chetner MP, Beatie J, et al. Screening for prostatic carcinoma with prostate specific antigen. J Urol 1992; 147:841.
- Catalona WJ, Smith DS, Ratliff TL, Basler JW. Detection of organ-confined prostate cancer is increased through prostate-specific antigen-based screening. JAMA 1993; 270:948.
- Crawford ED, DeAntoni EP, Etzioni R, et al. Serum prostate-specific antigen and digital rectal examination for early detection of prostate cancer in a national community-based program. The Prostate Cancer Education Council. Urology 1996; 47:863.
- Mettlin C, Lee F, Drago J, Murphy GP. The American Cancer Society National Prostate Cancer Detection Project. Findings on the detection of early prostate cancer in 2425 men. Cancer 1991; 67:2949.
- Wolf AM, Wender RC, Etzioni RB, et al. American Cancer Society guideline for the early detection of prostate cancer: update 2010. CA Cancer J Clin 2010; 60:70.
- Meigs JB, Barry MJ, Oesterling JE, Jacobsen SJ. Interpreting results of prostate-specific antigen testing for early detection of prostate cancer. J Gen Intern Med 1996; 11:505.
- Catalona WJ, Richie JP, Ahmann FR, et al. Comparison of digital rectal examination and serum prostate specific antigen in the early detection of prostate cancer: results of a multicenter clinical trial of 6,630 men. J Urol 1994; 151:1283.
- Schröder FH, van der Cruijsen-Koeter I, de Koning HJ, et al. Prostate cancer detection at low prostate specific antigen. J Urol 2000; 163:806.
- Coley CM, Barry MJ, Fleming C, Mulley AG. Early detection of prostate cancer. Part I: Prior probability and effectiveness of tests. The American College of Physicians. Ann Intern Med 1997; 126:394.
- Thompson IM, Pauler DK, Goodman PJ, et al. Prevalence of prostate cancer among men with a prostate-specific antigen level < or =4.0 ng per milliliter. N Engl J Med 2004; 350:2239.
- Catalona WJ, Smith DS, Ornstein DK. Prostate cancer detection in men with serum PSA concentrations of 2.6 to 4.0 ng/mL and benign prostate examination. Enhancement of specificity with free PSA measurements. JAMA 1997; 277:1452.
- Babaian RJ, Johnston DA, Naccarato W, et al. The incidence of prostate cancer in a screening population with a serum prostate specific antigen between 2.5 and 4.0 ng/ml: relation to biopsy strategy. J Urol 2001; 165:757.
- Gilbert SM, Cavallo CB, Kahane H, Lowe FC. Evidence suggesting PSA cutpoint of 2.5 ng/mL for prompting prostate biopsy: review of 36,316 biopsies. Urology 2005; 65:549.
- Porter MP, Stanford JL, Lange PH. The distribution of serum prostate-specific antigen levels among American men: implications for prostate cancer prevalence and screening. Prostate 2006; 66:1044.
- Thompson IM, Ankerst DP, Chi C, et al. Operating characteristics of prostate-specific antigen in men with an initial PSA level of 3.0 ng/ml or lower. JAMA 2005; 294:66.
- Welch HG, Schwartz LM, Woloshin S. Prostate-specific antigen levels in the United States: implications of various definitions for abnormal. J Natl Cancer Inst 2005; 97:1132.
- Carter HB. Prostate cancers in men with low PSA levels--must we find them? N Engl J Med 2004; 350:2292.
- Stamey TA, Johnstone IM, McNeal JE, et al. Preoperative serum prostate specific antigen levels between 2 and 22 ng./ml. correlate poorly with post-radical prostatectomy cancer morphology: prostate specific antigen cure rates appear constant between 2 and 9 ng./ml. J Urol 2002; 167:103.
- Labrie F, Candas B, Dupont A, et al. Screening decreases prostate cancer death: first analysis of the 1988 Quebec prospective randomized controlled trial. Prostate 1999; 38:83.
- Smith DS, Catalona WJ, Herschman JD. Longitudinal screening for prostate cancer with prostate-specific antigen. JAMA 1996; 276:1309.
- Grubb RL 3rd, Pinsky PF, Greenlee RT, et al. Prostate cancer screening in the Prostate, Lung, Colorectal and Ovarian cancer screening trial: update on findings from the initial four rounds of screening in a randomized trial. BJU Int 2008; 102:1524.
- Postma R, Schröder FH, van Leenders GJ, et al. Cancer detection and cancer characteristics in the European Randomized Study of Screening for Prostate Cancer (ERSPC)--Section Rotterdam. A comparison of two rounds of screening. Eur Urol 2007; 52:89.
- Brawer MK, Beatie J, Wener MH, et al. Screening for prostatic carcinoma with prostate specific antigen: results of the second year. J Urol 1993; 150:106.
- Polascik TJ, Oesterling JE, Partin AW. Prostate specific antigen: a decade of discovery--what we have learned and where we are going. J Urol 1999; 162:293.
- Carter HB, Pearson JD, Metter EJ, et al. Longitudinal evaluation of prostate-specific antigen levels in men with and without prostate disease. JAMA 1992; 267:2215.
- Nixon RG, Wener MH, Smith KM, et al. Biological variation of prostate specific antigen levels in serum: an evaluation of day-to-day physiological fluctuations in a well-defined cohort of 24 patients. J Urol 1997; 157:2183.
- Barry MJ. Clinical practice. Prostate-specific-antigen testing for early diagnosis of prostate cancer. N Engl J Med 2001; 344:1373.
- Cher ML, Carroll PR. Screening for prostate cancer. West J Med 1995; 162:235.
- Raaijmakers R, Wildhagen MF, Ito K, et al. Prostate-specific antigen change in the European Randomized Study of Screening for Prostate Cancer, section Rotterdam. Urology 2004; 63:316.
- Vickers AJ, Wolters T, Savage CJ, et al. Prostate-specific antigen velocity for early detection of prostate cancer: result from a large, representative, population-based cohort. Eur Urol 2009; 56:753.
- Roobol MJ, Kranse R, de Koning HJ, Schröder FH. Prostate-specific antigen velocity at low prostate-specific antigen levels as screening tool for prostate cancer: results of second screening round of ERSPC (ROTTERDAM). Urology 2004; 63:309.
- Thompson IM, Ankerst DP, Chi C, et al. Assessing prostate cancer risk: results from the Prostate Cancer Prevention Trial. J Natl Cancer Inst 2006; 98:529.
- Vickers AJ, Till C, Tangen CM, et al. An empirical evaluation of guidelines on prostate-specific antigen velocity in prostate cancer detection. J Natl Cancer Inst 2011; 103:462.
- Vickers AJ, Savage C, O'Brien MF, Lilja H. Systematic review of pretreatment prostate-specific antigen velocity and doubling time as predictors for prostate cancer. J Clin Oncol 2009; 27:398.
- Etzioni RD, Ankerst DP, Weiss NS, et al. Is prostate-specific antigen velocity useful in early detection of prostate cancer? A critical appraisal of the evidence. J Natl Cancer Inst 2007; 99:1510.
- Pinsky PF, Andriole G, Crawford ED, et al. Prostate-specific antigen velocity and prostate cancer gleason grade and stage. Cancer 2007; 109:1689.
- Stamey TA, Kabalin JN, McNeal JE, et al. Prostate specific antigen in the diagnosis and treatment of adenocarcinoma of the prostate. II. Radical prostatectomy treated patients. J Urol 1989; 141:1076.
- Benson MC, Whang IS, Olsson CA, et al. The use of prostate specific antigen density to enhance the predictive value of intermediate levels of serum prostate specific antigen. J Urol 1992; 147:817.
- Catalona WJ, Richie JP, deKernion JB, et al. Comparison of prostate specific antigen concentration versus prostate specific antigen density in the early detection of prostate cancer: receiver operating characteristic curves. J Urol 1994; 152:2031.
- Stephan C, Stroebel G, Heinau M, et al. The ratio of prostate-specific antigen (PSA) to prostate volume (PSA density) as a parameter to improve the detection of prostate carcinoma in PSA values in the range of < 4 ng/mL. Cancer 2005; 104:993.
- Catalona WJ, Partin AW, Slawin KM, et al. Use of the percentage of free prostate-specific antigen to enhance differentiation of prostate cancer from benign prostatic disease: a prospective multicenter clinical trial. JAMA 1998; 279:1542.
- Lee R, Localio AR, Armstrong K, et al. A meta-analysis of the performance characteristics of the free prostate-specific antigen test. Urology 2006; 67:762.
- Hoffman RM, Clanon DL, Littenberg B, et al. Using the free-to-total prostate-specific antigen ratio to detect prostate cancer in men with nonspecific elevations of prostate-specific antigen levels. J Gen Intern Med 2000; 15:739.
- Brawer MK, Meyer GE, Letran JL, et al. Measurement of complexed PSA improves specificity for early detection of prostate cancer. Urology 1998; 52:372.
- Partin AW, Brawer MK, Bartsch G, et al. Complexed prostate specific antigen improves specificity for prostate cancer detection: results of a prospective multicenter clinical trial. J Urol 2003; 170:1787.
- Catalona WJ, Partin AW, Sanda MG, et al. A multicenter study of [-2]pro-prostate specific antigen combined with prostate specific antigen and free prostate specific antigen for prostate cancer detection in the 2.0 to 10.0 ng/ml prostate specific antigen range. J Urol 2011; 185:1650.
- Guazzoni G, Nava L, Lazzeri M, et al. Prostate-specific antigen (PSA) isoform p2PSA significantly improves the prediction of prostate cancer at initial extended prostate biopsies in patients with total PSA between 2.0 and 10 ng/ml: results of a prospective study in a clinical setting. Eur Urol 2011; 60:214.
- Roobol MJ. Prostate cancer biomarkers to improve risk stratification: is our knowledge of prostate cancer sufficient to spare prostate biopsies safely? Eur Urol 2011; 60:223.
- McConnell JD, Barry MJ, Bruskewitz RC, et al. Benign Prostatic Hyperplasia: Diagnosis and Treatment. Clinical Practice Guidelines, AHCPR Publication no. 94-0582, Agency for Health Care Policy and Research; U.S. Department of Health and Human Services, Rockville, MD, 1994.
- Oesterling JE, Jacobsen SJ, Chute CG, et al. Serum prostate-specific antigen in a community-based population of healthy men. Establishment of age-specific reference ranges. JAMA 1993; 270:860.
- Catalona WJ, Hudson MA, Scardino PT, et al. Selection of optimal prostate specific antigen cutoffs for early detection of prostate cancer: receiver operating characteristic curves. J Urol 1994; 152:2037.
- Moul JW, Sesterhenn IA, Connelly RR, et al. Prostate-specific antigen values at the time of prostate cancer diagnosis in African-American men. JAMA 1995; 274:1277.
- Morgan TO, Jacobsen SJ, McCarthy WF, et al. Age-specific reference ranges for prostate-specific antigen in black men. N Engl J Med 1996; 335:304.
- Powell IJ, Banerjee M, Novallo M, et al. Should the age specific prostate specific antigen cutoff for prostate biopsy be higher for black than for white men older than 50 years? J Urol 2000; 163:146.
- Oesterling JE, Kumamoto Y, Tsukamoto T, et al. Serum prostate-specific antigen in a community-based population of healthy Japanese men: lower values than for similarly aged white men. Br J Urol 1995; 75:347.
- Tricoli JV, Schoenfeldt M, Conley BA. Detection of prostate cancer and predicting progression: current and future diagnostic markers. Clin Cancer Res 2004; 10:3943.
- Epstein JI. Pathology of prostatic neoplasia. In: Campbell's Urology, 8th ed, Walsh PC (Ed), Saunders, Philadelphia 2002.
- Krahn MD, Mahoney JE, Eckman MH, et al. Screening for prostate cancer. A decision analytic view. JAMA 1994; 272:773.
- Chodak GW, Keller P, Schoenberg HW. Assessment of screening for prostate cancer using the digital rectal examination. J Urol 1989; 141:1136.
- Smith DS, Catalona WJ. Interexaminer variability of digital rectal examination in detecting prostate cancer. Urology 1995; 45:70.
- Hoogendam A, Buntinx F, de Vet HC. The diagnostic value of digital rectal examination in primary care screening for prostate cancer: a meta-analysis. Fam Pract 1999; 16:621.
- Pedersen KV, Carlsson P, Varenhorst E, et al. Screening for carcinoma of the prostate by digital rectal examination in a randomly selected population. BMJ 1990; 300:1041.
- Richie JP, Catalona WJ, Ahmann FR, et al. Effect of patient age on early detection of prostate cancer with serum prostate-specific antigen and digital rectal examination. Urology 1993; 42:365.
- Gustafsson O, Norming U, Almgård LE, et al. Diagnostic methods in the detection of prostate cancer: a study of a randomly selected population of 2,400 men. J Urol 1992; 148:1827.
- Yamamoto T, Ito K, Ohi M, et al. Diagnostic significance of digital rectal examination and transrectal ultrasonography in men with prostate-specific antigen levels of 4 NG/ML or less. Urology 2001; 58:994.
- Smith RA, von Eschenbach AC, Wender R, et al. American Cancer Society guidelines for the early detection of cancer: update of early detection guidelines for prostate, colorectal, and endometrial cancers. Also: update 2001--testing for early lung cancer detection. CA Cancer J Clin 2001; 51:38.
- Bretton PR. Prostate-specific antigen and digital rectal examination in screening for prostate cancer: a community-based study. South Med J 1994; 87:720.
- Muschenheim F, Omarbasha B, Kardjian PM, Mondou EN. Screening for carcinoma of the prostate with prostate specific antigen. Ann Clin Lab Sci 1991; 21:371.
- Hessels D, Schalken JA. The use of PCA3 in the diagnosis of prostate cancer. Nat Rev Urol 2009; 6:255.
- Vlaeminck-Guillem V, Ruffion A, André J, et al. Urinary prostate cancer 3 test: toward the age of reason? Urology 2010; 75:447.
- Roobol MJ, Schröder FH, van Leeuwen P, et al. Performance of the prostate cancer antigen 3 (PCA3) gene and prostate-specific antigen in prescreened men: exploring the value of PCA3 for a first-line diagnostic test. Eur Urol 2010; 58:475.
- Bradley LA, Palomaki GE, Gutman S, et al. Comparative effectiveness review: prostate cancer antigen 3 testing for the diagnosis and management of prostate cancer. J Urol 2013; 190:389.
- Kerkhof M, Roobol MJ, Cuzick J, et al. Effect of the correction for noncompliance and contamination on the estimated reduction of metastatic prostate cancer within a randomized screening trial (ERSPC section Rotterdam). Int J Cancer 2010; 127:2639.
- Schröder FH, Hugosson J, Roobol MJ, et al. Screening and prostate cancer mortality: results of the European Randomised Study of Screening for Prostate Cancer (ERSPC) at 13 years of follow-up. Lancet 2014; 384:2027.
- Roobol MJ, Kerkhof M, Schröder FH, et al. Prostate cancer mortality reduction by prostate-specific antigen-based screening adjusted for nonattendance and contamination in the European Randomised Study of Screening for Prostate Cancer (ERSPC). Eur Urol 2009; 56:584.
- Barry MJ. Screening for prostate cancer--the controversy that refuses to die. N Engl J Med 2009; 360:1351.
- Wolters T, Roobol MJ, Steyerberg EW, et al. The effect of study arm on prostate cancer treatment in the large screening trial ERSPC. Int J Cancer 2010; 126:2387.
- Loeb S, Zhu X, Schroder FH, Roobol MJ. Long-term radical prostatectomy outcomes among participants from the European Randomized Study of Screening for Prostate Cancer (ERSPC) Rotterdam. BJU Int 2012; 110:1678.
- Newschaffer CJ, Otani K, McDonald MK, Penberthy LT. Causes of death in elderly prostate cancer patients and in a comparison nonprostate cancer cohort. J Natl Cancer Inst 2000; 92:613.
- Hugosson J, Carlsson S, Aus G, et al. Mortality results from the Göteborg randomised population-based prostate-cancer screening trial. Lancet Oncol 2010; 11:725.
- Arnsrud Godtman R, Holmberg E, Lilja H, et al. Opportunistic testing versus organized prostate-specific antigen screening: outcome after 18 years in the Göteborg randomized population-based prostate cancer screening trial. Eur Urol 2015; 68:354.
- Bill-Axelson A, Holmberg L, Filén F, et al. Radical prostatectomy versus watchful waiting in localized prostate cancer: the Scandinavian prostate cancer group-4 randomized trial. J Natl Cancer Inst 2008; 100:1144.
- Hayes JH, Barry MJ. Screening for prostate cancer with the prostate-specific antigen test: a review of current evidence. JAMA 2014; 311:1143.
- Andriole GL, Crawford ED, Grubb RL 3rd, et al. Prostate cancer screening in the randomized Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial: mortality results after 13 years of follow-up. J Natl Cancer Inst 2012; 104:125.
- Djulbegovic M, Beyth RJ, Neuberger MM, et al. Screening for prostate cancer: systematic review and meta-analysis of randomised controlled trials. BMJ 2010; 341:c4543.
- Ilic D, O'Connor D, Green S, Wilt TJ. Screening for prostate cancer: an updated Cochrane systematic review. BJU Int 2011; 107:882.
- Chou R, LeFevre ML. Prostate cancer screening--the evidence, the recommendations, and the clinical implications. JAMA 2011; 306:2721.
- Wilt TJ, Brawer MK, Jones KM, et al. Radical prostatectomy versus observation for localized prostate cancer. N Engl J Med 2012; 367:203.
- LAG, Eisner, MP, Kosary, CL, et al. SEER Cancer Statistics Review, 1973-1999. National Cancer Institute, Bethesda, MD, 2002.
- Bartsch G, Horninger W, Klocker H, et al. Prostate cancer mortality after introduction of prostate-specific antigen mass screening in the Federal State of Tyrol, Austria. Urology 2001; 58:417.
- Roberts RO, Bergstralh EJ, Katusic SK, et al. Decline in prostate cancer mortality from 1980 to 1997, and an update on incidence trends in Olmsted County, Minnesota. J Urol 1999; 161:529.
- Collin SM, Martin RM, Metcalfe C, et al. Prostate-cancer mortality in the USA and UK in 1975-2004: an ecological study. Lancet Oncol 2008; 9:445.
- Oliver SE, Gunnell D, Donovan JL. Comparison of trends in prostate-cancer mortality in England and Wales and the USA. Lancet 2000; 355:1788.
- Etzioni R, Tsodikov A, Mariotto A, et al. Quantifying the role of PSA screening in the US prostate cancer mortality decline. Cancer Causes Control 2008; 19:175.
- Heijnsdijk EA, Wever EM, Auvinen A, et al. Quality-of-life effects of prostate-specific antigen screening. N Engl J Med 2012; 367:595.
- Sox HC. Quality of life and guidelines for PSA screening. N Engl J Med 2012; 367:669.
- Gulati R, Gore JL, Etzioni R. Comparative effectiveness of alternative prostate-specific antigen--based prostate cancer screening strategies: model estimates of potential benefits and harms. Ann Intern Med 2013; 158:145.
- Concato J. Probability, uncertainty, and prostate cancer. Ann Intern Med 2013; 158:211.
- Rietbergen JB, Kruger AE, Kranse R, Schröder FH. Complications of transrectal ultrasound-guided systematic sextant biopsies of the prostate: evaluation of complication rates and risk factors within a population-based screening program. Urology 1997; 49:875.
- Loeb S, Carter HB, Berndt SI, et al. Complications after prostate biopsy: data from SEER-Medicare. J Urol 2011; 186:1830.
- Nam RK, Saskin R, Lee Y, et al. Increasing hospital admission rates for urological complications after transrectal ultrasound guided prostate biopsy. J Urol 2010; 183:963.
- AUA/SUNA white paper on the incidence, prevention and treatment of complications related to prostate needle biopsy. www.auanet.org/content/health-policy/quality/pdf/AUA-SUNA-PNBWhitePaper.pdf (Accessed on November 30, 2012).
- Wagenlehner FM, van Oostrum E, Tenke P, et al. Infective complications after prostate biopsy: outcome of the Global Prevalence Study of Infections in Urology (GPIU) 2010 and 2011, a prospective multinational multicentre prostate biopsy study. Eur Urol 2013; 63:521.
- Gallina A, Suardi N, Montorsi F, et al. Mortality at 120 days after prostatic biopsy: a population-based study of 22,175 men. Int J Cancer 2008; 123:647.
- Boniol M, Boyle P, Autier P, et al. Critical role of prostate biopsy mortality in the number of years of life gained and lost within a prostate cancer screening programme. BJU Int 2012; 110:1648.
- Rosario DJ, Lane JA, Metcalfe C, et al. Short term outcomes of prostate biopsy in men tested for cancer by prostate specific antigen: prospective evaluation within ProtecT study. BMJ 2012; 344:d7894.
- Loeb S, van den Heuvel S, Zhu X, et al. Infectious complications and hospital admissions after prostate biopsy in a European randomized trial. Eur Urol 2012; 61:1110.
- Essink-Bot ML, de Koning HJ, Nijs HG, et al. Short-term effects of population-based screening for prostate cancer on health-related quality of life. J Natl Cancer Inst 1998; 90:925.
- McNaughton-Collins M, Fowler FJ Jr, Caubet JF, et al. Psychological effects of a suspicious prostate cancer screening test followed by a benign biopsy result. Am J Med 2004; 117:719.
- Fowler FJ Jr, Barry MJ, Walker-Corkery B, et al. The impact of a suspicious prostate biopsy on patients' psychological, socio-behavioral, and medical care outcomes. J Gen Intern Med 2006; 21:715.
- Klotz LH. PSAdynia and other PSA-related syndromes: a new epidemic--a case history and taxonomy. Urology 1997; 50:831.
- Epstein JI, Walsh PC, Carmichael M, Brendler CB. Pathologic and clinical findings to predict tumor extent of nonpalpable (stage T1c) prostate cancer. JAMA 1994; 271:368.
- Breslow N, Chan CW, Dhom G, et al. Latent carcinoma of prostate at autopsy in seven areas. The International Agency for Research on Cancer, Lyons, France. Int J Cancer 1977; 20:680.
- Sakr WA, Grignon DJ, Haas GP, et al. Age and racial distribution of prostatic intraepithelial neoplasia. Eur Urol 1996; 30:138.
- Haas GP, Sakr WA. Epidemiology of prostate cancer. CA Cancer J Clin 1997; 47:273.
- Etzioni R, Penson DF, Legler JM, et al. Overdiagnosis due to prostate-specific antigen screening: lessons from U.S. prostate cancer incidence trends. J Natl Cancer Inst 2002; 94:981.
- Draisma G, Etzioni R, Tsodikov A, et al. Lead time and overdiagnosis in prostate-specific antigen screening: importance of methods and context. J Natl Cancer Inst 2009; 101:374.
- Schröder FH, Hugosson J, Roobol MJ, et al. Prostate-cancer mortality at 11 years of follow-up. N Engl J Med 2012; 366:981.
- Welch HG, Albertsen PC. Prostate cancer diagnosis and treatment after the introduction of prostate-specific antigen screening: 1986-2005. J Natl Cancer Inst 2009; 101:1325.
- Pashayan N, Duffy SW, Pharoah P, et al. Mean sojourn time, overdiagnosis, and reduction in advanced stage prostate cancer due to screening with PSA: implications of sojourn time on screening. Br J Cancer 2009; 100:1198.
- Trinh QD, Sun M, Kim SP, et al. The impact of hospital volume, residency, and fellowship training on perioperative outcomes after radical prostatectomy. Urol Oncol 2014; 32:29.e13.
- Begg CB, Riedel ER, Bach PB, et al. Variations in morbidity after radical prostatectomy. N Engl J Med 2002; 346:1138.
- Lu-Yao GL, Albertsen P, Warren J, Yao SL. Effect of age and surgical approach on complications and short-term mortality after radical prostatectomy--a population-based study. Urology 1999; 54:301.
- Harris R, Lohr KN. Screening for prostate cancer: an update of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2002; 137:917.
- Stanford JL, Feng Z, Hamilton AS, et al. Urinary and sexual function after radical prostatectomy for clinically localized prostate cancer: the Prostate Cancer Outcomes Study. JAMA 2000; 283:354.
- Hamilton AS, Stanford JL, Gilliland FD, et al. Health outcomes after external-beam radiation therapy for clinically localized prostate cancer: results from the Prostate Cancer Outcomes Study. J Clin Oncol 2001; 19:2517.
- McNaughton-Collins MF, Barry MJ. One man at a time--resolving the PSA controversy. N Engl J Med 2011; 365:1951.
- Schröder FH. Stratifying risk--the U.S. Preventive Services Task Force and prostate-cancer screening. N Engl J Med 2011; 365:1953.
- Volk RJ, Wolf AM. Grading the new US Preventive Services Task Force prostate cancer screening recommendation. JAMA 2011; 306:2715.
- U.S. Preventive Services Task Force. Screening for prostate cancer: recommendation and rationale. Ann Intern Med 2002; 137:915.
- Qaseem A, Barry MJ, Denberg TD, et al. Screening for prostate cancer: a guidance statement from the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med 2013; 158:761.
- www.auanet.org/education/guidelines/prostate-cancer-detection.cfm (Accessed on May 06, 2013).
- Feightner JW. Recommendations on secondary prevention of prostate cancer from the Canadian Task Force on the Periodic Health Examination. Can J Oncol 1994; 4 Suppl 1:80.
- Screening for prostate cancer. American College of Physicians. Ann Intern Med 1997; 126:480.
- Ganz PA, Barry JM, Burke W, et al. National Institutes of Health State-of-the-Science Conference: role of active surveillance in the management of men with localized prostate cancer. Ann Intern Med 2012; 156:591.
- Dunn AS, Shridharani KV, Lou W, et al. Physician-patient discussions of controversial cancer screening tests. Am J Prev Med 2001; 20:130.
- Barry MJ. Health decision aids to facilitate shared decision making in office practice. Ann Intern Med 2002; 136:127.
- Hoffman RM. Clinical practice. Screening for prostate cancer. N Engl J Med 2011; 365:2013.
- Frosch DL, Kaplan RM, Felitti V. The evaluation of two methods to facilitate shared decision making for men considering the prostate-specific antigen test. J Gen Intern Med 2001; 16:391.
- Flood AB, Wennberg JE, Nease RF Jr, et al. The importance of patient preference in the decision to screen for prostate cancer. Prostate Patient Outcomes Research Team. J Gen Intern Med 1996; 11:342.
- Volk RJ, Cass AR, Spann SJ. A randomized controlled trial of shared decision making for prostate cancer screening. Arch Fam Med 1999; 8:333.
- Wolf AM, Nasser JF, Wolf AM, Schorling JB. The impact of informed consent on patient interest in prostate-specific antigen screening. Arch Intern Med 1996; 156:1333.
- Davison BJ, Kirk P, Degner LF, Hassard TH. Information and patient participation in screening for prostate cancer. Patient Educ Couns 1999; 37:255.
- Schapira MM, VanRuiswyk J. The effect of an illustrated pamphlet decision-aid on the use of prostate cancer screening tests. J Fam Pract 2000; 49:418.
- Wilt TJ, Paul J, Murdoch M, et al. Educating men about prostate cancer screening. A randomized trial of a mailed pamphlet. Eff Clin Pract 2001; 4:112.
- Volk RJ, Hawley ST, Kneuper S, et al. Trials of decision aids for prostate cancer screening: a systematic review. Am J Prev Med 2007; 33:428.
- Taylor KL, Williams RM, Davis K, et al. Decision making in prostate cancer screening using decision aids vs usual care: a randomized clinical trial. JAMA Intern Med 2013; 173:1704.
- Liede A, Karlan BY, Narod SA. Cancer risks for male carriers of germline mutations in BRCA1 or BRCA2: a review of the literature. J Clin Oncol 2004; 22:735.
- Mitra AV, Bancroft EK, Barbachano Y, et al. Targeted prostate cancer screening in men with mutations in BRCA1 and BRCA2 detects aggressive prostate cancer: preliminary analysis of the results of the IMPACT study. BJU Int 2011; 107:28.
- Bancroft EK, Page EC, Castro E, et al. Targeted prostate cancer screening in BRCA1 and BRCA2 mutation carriers: results from the initial screening round of the IMPACT study. Eur Urol 2014; 66:489.
- Roobol MJ, Grenabo A, Schröder FH, Hugosson J. Interval cancers in prostate cancer screening: comparing 2- and 4-year screening intervals in the European Randomized Study of Screening for Prostate Cancer, Gothenburg and Rotterdam. J Natl Cancer Inst 2007; 99:1296.
- Ross KS, Carter HB, Pearson JD, Guess HA. Comparative efficiency of prostate-specific antigen screening strategies for prostate cancer detection. JAMA 2000; 284:1399.
- Crawford ED, Pinsky PF, Chia D, et al. Prostate specific antigen changes as related to the initial prostate specific antigen: data from the prostate, lung, colorectal and ovarian cancer screening trial. J Urol 2006; 175:1286.
- Schröder FH, Raaijmakers R, Postma R, et al. 4-year prostate specific antigen progression and diagnosis of prostate cancer in the European Randomized Study of Screening for Prostate Cancer, section Rotterdam. J Urol 2005; 174:489.
- Candas B, Labrie F, Gomez JL, et al. Relationship among initial serum prostate specific antigen, prostate specific antigen progression and prostate cancer detection at repeat screening visits. J Urol 2006; 175:510.
- Kundu SD, Grubb RL, Roehl KA, et al. Delays in cancer detection using 2 and 4-year screening intervals for prostate cancer screening with initial prostate specific antigen less than 2 ng/ml. J Urol 2005; 173:1116.
- Prestigiacomo AF, Stamey TA. Physiological variation of serum prostate specific antigen in the 4.0 to 10.0 ng./ml. range in male volunteers. J Urol 1996; 155:1977.
- Eastham JA, Riedel E, Scardino PT, et al. Variation of serum prostate-specific antigen levels: an evaluation of year-to-year fluctuations. JAMA 2003; 289:2695.
- Louie KS, Seigneurin A, Cathcart P, Sasieni P. Do prostate cancer risk models improve the predictive accuracy of PSA screening? A meta-analysis. Ann Oncol 2015; 26:848.
- Fleshner NE, O'Sullivan M, Fair WR. Prevalence and predictors of a positive repeat transrectal ultrasound guided needle biopsy of the prostate. J Urol 1997; 158:505.
- Djavan B, Zlotta A, Remzi M, et al. Optimal predictors of prostate cancer on repeat prostate biopsy: a prospective study of 1,051 men. J Urol 2000; 163:1144.
- Djavan B, Ravery V, Zlotta A, et al. Prospective evaluation of prostate cancer detected on biopsies 1, 2, 3 and 4: when should we stop? J Urol 2001; 166:1679.
- Roobol MJ, van der Cruijsen IW, Schröder FH. No reason for immediate repeat sextant biopsy after negative initial sextant biopsy in men with PSA level of 4.0 ng/mL or greater (ERSPC, Rotterdam). Urology 2004; 63:892.
- Roobol MJ, Schröder FH, Kranse R, ERSPC, Rotterdam. A comparison of first and repeat (four years later) prostate cancer screening in a randomized cohort of a symptomatic men aged 55-75 years using a biopsy indication of 3.0 ng/ml (results of ERSPC, Rotterdam). Prostate 2006; 66:604.
- Carter HB, Landis PK, Metter EJ, et al. Prostate-specific antigen testing of older men. J Natl Cancer Inst 1999; 91:1733.
- Vickers AJ, Cronin AM, Björk T, et al. Prostate specific antigen concentration at age 60 and death or metastasis from prostate cancer: case-control study. BMJ 2010; 341:c4521.
- Lu-Yao GL, Albertsen PC, Moore DF, et al. Outcomes of localized prostate cancer following conservative management. JAMA 2009; 302:1202.
- Albertsen PC, Moore DF, Shih W, et al. Impact of comorbidity on survival among men with localized prostate cancer. J Clin Oncol 2011; 29:1335.
- Fleming C, Wasson JH, Albertsen PC, et al. A decision analysis of alternative treatment strategies for clinically localized prostate cancer. Prostate Patient Outcomes Research Team. JAMA 1993; 269:2650.
- http://www.uspreventiveservicestaskforce.org/prostatecancerscreening/prostatefinalrs.htm (Accessed on May 21, 2012).
- Canadian Task Force on Preventive Health Care, Bell N, Connor Gorber S, et al. Recommendations on screening for prostate cancer with the prostate-specific antigen test. CMAJ 2014; 186:1225.
- www.screening.nhs.uk/prostatecancer (Accessed on December 20, 2010).
- www.cancer.org.au/File/PolicyPublications/Position_statements/PS_prostate_cancer_screening_updated_June_2010.pdf (Accessed on January 03, 2011).
- Horwich A, Hugosson J, de Reijke T, et al. Prostate cancer: ESMO Consensus Conference Guidelines 2012. Ann Oncol 2013; 24:1141.