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Screening for Prostate Cancer: U.S. Preventive Services Task Force Recommendation Statement (continued)

Table. PSA-Based Screening for Prostate Cancer*

Why not screen for prostate cancer?
Screening may benefit a small number of men but will result in harm to many others. A person choosing to be screened should believe that the possibility of benefit is more important than the risk for harm. The USPSTF assessment of the balance of benefits and harms in a screened population is that the benefits do not outweigh the harms.
What are the benefits and harms of screening 1000 men aged 55–69 y with a PSA test every 1-4 y for 10 y?
Possible benefit of screening Men, n
Reduced 10-y risk for dying of prostate cancer
    Die of prostate cancer with no screening
    Die of prostate cancer with screening
    Do not die of prostate cancer because of screening
 
5 in 1000
4–5 in 1000
0–1 in 1000
Harms of screening
At least 1 false-positive screening PSA test result
Most positive test results lead to biopsy. Of men having biopsy, up to 33% will have moderate or major bothersome symptoms, including pain, fever, bleeding, infection, and temporary urinary difficulties; 1% will be hospitalized.
 
100–120 in 1000
Prostate cancer diagnosis
Although a diagnosis of prostate cancer may not be considered a harm, currently 90% of diagnosed men are treated and, thus, are at risk for the harms of treatment. A large majority of the men who are being treated would do well without treatment. A substantial percentage of these men would have remained asymptomatic for life.
 
110 in 1000
Complications of treatment (of those who are screened)
    Develop serious cardiovascular events due to treatment
    Develop deep venous thrombosis or pulmonary embolus due to treatment
    Develop erectile dysfunction due to treatment
    Develop urinary incontinence due to treatment
    Die due to treatment
 
2 in 1000
1 in 1000
29 in 1000
18 in 1000
<1 in 1000

PSA = prostate-specific antigen; USPSTF = U.S. Preventive Services Task Force.
* The table design is adapted from Woloshin and Schwartz (14). Calculations of the estimated benefits and harms rely on assumptions and are, by nature, somewhat imprecise. Estimates should be considered in the full context of clinical decision making and used to stimulate shared decision making.
The best evidence of possible benefit of PSA screening is in men aged 55–69 y.
The rate of complications depends on the proportion of men having treatment and the method of treatment. The table reflects a distribution of 60% surgical treatment, 30% radiation, and 10% observation (refer to below for more details about assumptions and references). Other harms of radiation, such as bowel damage, are not shown.

Note: Estimates of the number of prostate cancer deaths in screened and unscreened men are taken from the 11- and 13-year follow-up studies of the PLCO (23) and ERSPC (15) trials. False-positive rates for PSA tests are derived from the PLCO trial and the Finnish center of the ERSPC trial (47, 64). Information related to the harms of biopsy is derived from the work of Rosario and colleagues (6). The incidence of prostate cancer in a screened population is derived from the incidence seen in the screened group of the PLCO trial (23). Treatment rates for localized prostate cancer in the U.S. population are derived from the SEER database and the Cancer of the Prostate Strategic Urologic Research Endeavor registry (9, 10). Expected complication rates from prostatectomy and radiation therapy are derived from pooled estimates calculated in the evidence review done for the USPSTF (10).

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