The US Preventive Services Task Force (USPSTF) grades its recommendations (A, B, C, D, or I) and identifies the Levels of Certainty regarding Net Benefit (High, Moderate, and Low). The definitions of these grades can be found at the end of the "Major Recommendations" field.
Summary of Recommendations and Evidence
- The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of prostate cancer screening in men younger than age 75 years.
This is an I statement.
- The USPSTF recommends against screening for prostate cancer in men age 75 years or older. This is a grade D recommendation.
Clinical Considerations
Patient Population under Consideration
This recommendation applies to men in the general U.S. population.
Risk Assessment
Older men, African-American men, and men with a family history of prostate cancer are at increased risk for diagnosis and death from prostate cancer. Unfortunately, the previously described gaps in the evidence regarding potential benefits of screening also apply to these men.
Screening Tests
The prostate-specific antigen (PSA) test is more sensitive than the digital rectal examination for detecting prostate cancer. The conventional PSA screening cut-point of 4.0 micrograms/L detects many prostate cancer cases; however, some early cases of prostate cancer will be missed by this cut-point. Using a lower cut-point to define an abnormal PSA detects more cases of cancer.
The proportion of cancer cases detected by lower cutpoints that would ever become clinically apparent is unknown; lower cut-points would label many more men as potentially having cancer. For example, lowering the PSA cut-point to 2.5 micrograms/L would more than double the number of U.S. men between 40 and 69 years of age with abnormal results.
Variations of PSA screening, including the use of age-adjusted PSA cut-points, free PSA, PSA density, PSA velocity, PSA slope, and PSA doubling time, have been proposed to improve detection of "clinically important" prostate cancer cases. However, no evidence suggests that any of these testing strategies improves health outcomes.
Suggestions for Practice
Given the uncertainties and controversy surrounding prostate cancer screening in men younger than age 75 years, a clinician should not order the PSA test without first discussing with the patient the potential but uncertain benefits and the known harms of prostate cancer screening and treatment. Men should be informed of the gaps in the evidence and should be assisted in considering their personal preferences before deciding whether to be tested.
Treatment
Because of the uncertainty about the benefits of treating prostate cancer detected by screening men younger than age 75 years, there is no consensus regarding optimal treatment. Current management strategies for localized prostate cancer include watchful waiting (observation with palliative treatment for symptoms only), active surveillance (periodic biochemical monitoring with conversion to curative treatment for signs of disease progression), radical prostatectomy, external-beam radiation therapy, and brachytherapy (or radioactive seed implantation therapy).
If treatment for prostate cancer detected by screening improves health outcomes, the population most likely to benefit from screening will be men age 50 to 74 years. Even if prostate cancer screening is determined to be effective, the length of time required to experience a mortality benefit is greater than 10 years. Because a 75-year-old man has an average life expectancy of about 10 years, very few men age 75 years or older would experience a mortality benefit. Similarly, men younger than age 75 years who have chronic medical problems and a life expectancy of fewer than 10 years are also unlikely to benefit from screening and treatment.
Screening Intervals
The yield of screening in terms of cancer cases detected declines rapidly with repeated annual testing. If screening were to reduce deaths, PSA screening as infrequent as every 4 years could yield as much of a benefit as annual screening.
Definitions:
What the United States Preventive Services Task Force (USPSTF) Grades Mean and Suggestions for Practice
| Grade |
Grade Definitions |
Suggestions for Practice |
| A |
The USPSTF recommends the service. There is high certainty that the net benefit is substantial. |
Offer or provide this service. |
| B |
The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. |
Offer or provide this service. |
| C |
The USPSTF recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient. There is moderate or high certainty that the net benefit is small. |
Offer/provide this service only if there are other considerations in support of the offering/providing the service in an individual patient. |
| D |
The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. |
Discourage the use of this service. |
I
Statement
|
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality or conflicting, and the balance of benefits and harms cannot be determined. |
Read "Clinical Considerations" section of USPSTF Recommendation Statement (see "Major Recommendations" field). If offered, patients should understand the uncertainty about the balance of benefits and harms. |
USPSTF Levels of Certainty Regarding Net Benefit
Definition: The U.S. Preventive Services Task Force defines certainty as "likelihood that the USPSTF assessment of the net benefit of a preventive service is correct." The net benefit is defined as benefit minus harm of the preventive service as implemented in a general, primary care population. The USPSTF assigns a certainty level based on the nature of the overall evidence available to assess the net benefit of a preventive service.
| Level of Certainty |
Description |
| High |
The available evidence usually includes consistent results from well-designed, well-conducted studies in representative primary care populations. These studies assess the effects of the preventive service on health outcomes. This conclusion is therefore unlikely to be strongly affected by the results of future studies. |
| Moderate |
The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by factors such as:
- The number, size, or quality of individual studies
- Inconsistency of findings across individual studies
- Limited generalizability of findings to routine primary care practice
- Lack of coherence in the chain of evidence
As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion.
|
| Low |
The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient because of:
- The limited number or size of studies
- Important flaws in study design or methods
- Inconsistency of findings across individual studies
- Gaps in the chain of evidence
- Findings not generalizable to routine primary care practice
- A lack of information on important health outcomes
More information may allow an estimation of effects on health outcomes.
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