Optimizing Patient Care

Prostate E-Newsletter

Issue III - 07.2017

In This Issue...

  1. Optimizing Patient Care
  2. Prostate Screening
  3. Recommendations
  4. Implementation
  5. Shared Decision Making
  6. Resources

Optimizing Patient Care: Prostate Screening


Optimizing Patient Care: Incorporating "Choosing Wisely®" Recommendations into Practice

The IAFP is pleased to continue the e-newsletter series regarding incorporating "Choosing Wisely®" recommendations into practice. Each newsletter will have a specific focus, with the third being Prostate Screening. This issue, along with each e-newsletter, will contain recommendations, updates, links to resources, and strategies for you to implement in your practice.

This newsletter was created by the Illinois Academy of Family Physicians and is made possible by funds received from:

  • American Academy of Family Physicians through its program, The Family Medicine Philanthropic Consortium
  • Blue Cross and Blue Shield of Illinois
  • The Telligen Community Initiative

Online Education Videos

 In addition to the e-newsletter series, IAFP now has two online enduring educational offerings:

  • Optimizing Patient Care. The first being Optimizing Patient Care: Incorporating "Choosing Wisely®" Into Practice
  • Optimizing Patient Care: Antibiotic Stewardship

Visit IAFP's Education website today to learn more!

Prostate Screening

Prostate cancer is the second most common form of cancer and the second leading cause of cancer death among men in the United States. In 2013, 176,450 men were diagnosed with prostate cancer and 27,681 men died from the disease. Estimates for 2016, are approximately 180,890 men will be diagnosed with prostate cancer and 26,120 will die. The Prostate-specific Antigen (PSA) test is used by physicians to screen for prostate cancer.

PSA blood test: Is it necessary?

For years, the standard protocol of physicians has been to administer a PSA blood test to screen men for prostate cancer. Higher PSA has been considered a potential marker for cancer. PSA screening, originally developed as a tumor marker to track disease reoccurrence or progression following treatment for prostate cancer, began to be used for routine cancer screening by the 1990s. The result was an increase in diagnosis of prostate cancer as well as an increase in treatment including radical prostatectomy and radiation.

The necessity of routine PSA screening has been called into question, however, for several reasons. A higher PSA does not positively correlate with the existence of cancer in most men; higher PSA may be an indicator of cancer in only about 25% of men. Reasons for higher PSA include: enlarged prostate gland, prostate infection, recent sexual activity, and a long bike ride. Another reason PSA screening may not be necessary is that the majority of cancers found are localized. Further, in most cases, prostate cancer does not grow or cause symptoms, especially in older men. If prostate cancer does grow, it often grows so slowly that it is not expected to cause health problems. Currently, screening is not able to reliably distinguish between prostate cancer that will not (or be slow to) progress and prostate cancer that will be aggressive.

Prostate Screening: Recommendations

As part of the Choosing Wisely® campaign, the American Academy of Family Physicians (AAFP) identified 15 clinical recommendations. Recommendation 13 on prostate screening was released in the third phase of the campaign, which included recommendations 11 through 15. The goal of phase 3 was to identify items common in the practice of family medicine supported by a review of the evidence that would lead to significant health benefits, reduce risks, harms and costs. For each recommendation, evidence was reviewed from appropriate sources such as the Cochrane Collaboration, the Agency for Healthcare Research and Quality and other sources. The AAFP's Commission on Health of the Public and Science and Board of Directors reviewed and approved the recommendations. Choosing Wisely® is an initiative of the ABIM. Additional information is available at: http://www.choosingwisely.org/.

Choosing Wisely® Recommendation on Prostate Screening:

Do not routinely screen for prostate cancer using a prostate-specific antigen (PSA) test or digital rectal exam (DRE).

 There is convincing evidence that PSA-based screening leads to substantial over-diagnosis of prostate tumors.

 Many tumors will not harm patients, while the risks of treatment are significant.

Physicians should not offer or order PSA screening unless they are prepared to engage in shared decision making that enables an informed choice by patients.

Recommendation on Prostate Screening

In May 2012, the U.S. Preventive Services Task Force (USPSTF) issued the following final recommendation statement on prostate screening:

The U.S. Preventive Services Task Force recommends against prostate-specific antigen (PSA)-based screening for prostate cancer.

Note: This recommendation is currently being updated. See Update in Progress section of USPSTF recommendation for more information.

The recommendation was reached after an extensive review of the medical literature. It applies to men of all ages. The recommendation, however, does not apply to men who have been diagnosed with or who are being treated for prostate cancer.

Evidence-based Recommendations

Studies show that 5 out of every 1,000 men will die from prostate cancer after 10 years in an unscreened population. In a screened population, 4 to 5 out of every 1,000 men will die after 10 years. Therefore, PSA screening may, at best, help 1 out of 1,000 men avoid death from prostate cancer after at least 10 years.

Evidence also shows that prostate cancer screening leads to false-positive results, over-diagnosis, and overtreatment.

False-positive results:  Approximately 100-120 of every 1,000 men who undergo PSA screening for prostate cancer are given a false-positive test result. One-third of the men who undergo biopsy will experience fever, infection, bleeding, urinary problems and/or pain.

Over-diagnosis:  Evidence shows that PSA screening identifies many cancers that are asymptomatic and that the tumors identified will either not progress or will progress very slowly and not cause harm to patients. Many cancers that are diagnosed would have remained asymptomatic and would not have required treatment.

Over-treatment:  The vast majority (90%) of men diagnosed with cancer after PSA screening choose to undergo treatment. Potential harms associated with surgery, radiation therapy or hormone therapy including erectile dysfunction, urinary incontinence, and death and serious complications from surgery - this last risk is small.

Other potential harms from screening include, anxiety associated with screening and treatments and high costs of diagnosis and treatment.

For more information, refer to the Rationale section of the USPSTF final recommendation statement, the USPSTF article entitled Talking With Your Patients About Screening for Prostate Cancer available here under the Related Information for Health Professionals section and an article entitled PSA Blood Test for Prostate Cancer.

National Cancer Institute Research-tested Intervention Programs (RTIPs)

The RTIPs website is sponsored by the National Cancer Institute. The website provides a review of evidenced-based cancer control programs that can be used in a clinical (or community) setting. Further, it provides a searchable data base of programs. Included in in the data base is information on the RTIP Program entitled Prostate Cancer Screening: Making the Best Decision. This program uses a self-guided web-based approach to help men (age 50-70) make informed decisions about whether or not to be screened for prostate cancer.

Prostate Screening: Implementation

Since the release of the 2012 USPSTF recommendation on prostate cancer screening, studies have found declines in incidence of early-stage prostate cancer detection and rates of PSA screenings. One study of men aged 50 and over (N=446,009) found the incidence of prostate cancer per 100,000 began decreasing in 2008 and decreased the most between 2011(498.3) and 2012 (416.2). The number of men diagnosed during this same time period, declined from 213,562 to 180,043, meaning 33,519 fewer men received a diagnosis of prostate cancer between 2011 and 2012. Further, among men age 50 and over, PSA screening was found to decrease about 18% between 2010 and 2013.

Another study of men age 50 and over (N=20,757) found that the prevalence of screening decreased from 36% to 31% between 2010 and 2013. Further, a study found a national decline in self-reported PSA screenings after the release of the 2012 USPSTF recommendation against PSA-screening for prostate cancer. Declines were reported in all age groups, but most notably in men between the ages of 50 and 59.

Studies showing declines in prostate screening rates since 2012 indicate that physicians are following the USPSTF recommendation. Concern has been raised, however, that physicians are not following the recommendation for all age groups. For example, in 2013, over 1.4 million (or about one-third) of men age 65 and over who had a high probability (greater than 52%) of death in the next 9 years, were still screened.

Prostate Screening: Shared Decision-Making

Shared decision-making between physician and patient is the focus of the American Urological Society's June 2015 recommendation on prostate screening:

Offer PSA screening for detecting prostate cancer only after engaging in shared decision making.

Shared decision making (between health care provider and patient and, in some cases, family members) is an excellent strategy for making health care decisions when there is more than one medically reasonable option. Since both screening and not screening may be reasonable options, depending on the particular situation, shared decision making is recommended.

Whether or not to order a PSA screen should be based on a conversation with the patient. This discussion should include the possible benefits and risks of the test (refer to information in the "Evidenced-based Recommendations" section above).

 The USPSTF states, "physicians should not feel obligated to offer PSA testing if a patient does not raise the issue or request the test." If physician believes a patient warrants consideration of screening, the physician should discuss this with the patient. "The decision to start or continue PSA screening should reflect [the] patient's understanding of the possible benefits and expected harms and should respect his preferences."

Note, however that Consumer Reports provides the following advice to patients on talking with their physicians about prostate screening:

If you are age 50 to 74, you should discuss the PSA test with your doctor. Ask about the possible risks and benefits. Men under 50 or over 75 rarely need a PSA test, unless they have a high risk for prostate cancer.

  • You are more likely to get prostate cancer if you have a family history of prostate cancer, especially in a close relative such as a parent or sibling.
  • Your risks are higher if your relative got prostate cancer before age 60 or died from it before age 75. These early cancers are more likely to grow faster.
  • If you have these risks, you may want to ask your doctor about getting the PSA test before age 50.

Online Resources

Choosing Wisely®.Screening tests: When you need them - When you don't. Available:


Hoffman RM. UpToDate. Screening for prostate cancer. Available: http://www.uptodate.com/contents/screening-for-prostate-cancer

Lin et al. Prostate-specific antigen-based screening for prostate cancer. Evidence Synthesis No. 90. Available: http://www.ncbi.nlm.nih.gov/books/NBK82303/

Mulhelm E, Fulbright N, Duncan N. Prostate cancer screening. Am Fam Physician. 2015 Oct 15;92(8):683-688.

USPSTF. How did the USPSTF arrive at this recommendation? Other supporting document for prostate cancer: screening. Available:  https://www.uspreventiveservicestaskforce.org/Page/Document/how-did-the-uspstf-arrive-at-this-recommendation-/prostate-cancer-screening#ten


Illinois Academy of Family Physicians
747 E. Boughton Road, Ste. 253

Bolingbrook, IL 60440