Ecase #D-3

Eric Liu, M.D.

January 6-10, 2003

Patient is a 59 y.o. Black male, with no significant PMH, who presents for a physical.  He desires screening for prostate cancer, but is unsure of the current recommendations.  What are the current viewpoints and the evidence for and against screening?  In summary, there are a number of points to consider.

• Many more men receive a diagnosis of prostate cancer than die of it (l:6 men diagnosed in lifetime  versus 1:29 die from prostate cancer, as estimated by the American Cancer Society).

• Older men with a life expectancy of fewer than 10 years are unlikely to benefit from screening.

• Groups most likely to benefit are ages-50-70 and those over 45 at a higher risk (African-American men and those with a first degree relative with cancer).

• When used for screening, the combination of PSA and DRE is approximately 59% sensitive.

• 10-20% of men with prostate cancer will have a normal PSA and abnormal digital rectal exam (DRE) at the time of presentation.

• One randomized study of screening (PSA combined with DRE) showed no difference in rate of cancer deaths (4.6 versus 4.8 per 1000 persons over eight-year study period).

• Men with prostate cancer have a lower percentage of free PSA.

• Men with prostate cancer have a greater increase in PSA level over time; no evidence available whether use of "PSA velocity" improves outcomes or reduces biopsies.

• Recent evidence suggests that radical prostatectomy can reduce prostate cancer mortality and morbidity (7.1% versus 13.6% : prostatectomy versus waiting).

• In a large cohort study, 10-year survival rates in external beam radiation were similar to waiting for well and moderately well differentiated tumors, and higher in poorly differentiated cancer.

• A 1993 decision analysis (using the most optimistic assumptions) found that early screening and treatment provided little or no benefit for men with well-differentiated tumors.  Screening and early treatment could offer 3.5 years of improvement in quality-adjusted life expectancy for moderately or poorly differentiated cancer.  Men over 75 years appeared to receive no benefit.

Two important organizations have made the following recommendations:

• The U.S. Preventive Services Task Force concludes that the evidence is insufficient to recommend for or against routine screening for prostate cancer.

• ACP-ASIM recommends individualizing one's approach by discussing risks and benefits with each patient.

In this particular case, one could consider the patient's higher risk category and favor screening after discussing the pros and cons of either approach.