TABLE 4.5

Prostate Cancer Screening Recommendations

Organization

Recommendation

American Cancer Society

Offer annual PSA testing to men over age 50 who have at least a 10-year life expectancy. Counsel certain high-risk groups (those with a family history including two or more first-degree relatives and African-American men) to begin testing at earlier ages (e.g., 45) (von Eschenbach et al., 1997)

American Urological Association

Offer the PSA test to men over age 50 who present for evaluation of prostatic disease symptoms after counseling them on the risks and benefits of the test. For men at high risk (positive family history, African American) the recommended age is 40 (Correa, 1998)

National Cancer Institute's PDQ

Evidence is insufficient to establish whether improvements in survival are associated with prostate cancer screening by DRE, TRUS, or PSA testing

U.S. Preventive Services Task Force (1996)

Routine screening is not recommended because of insufficient evidence regarding efficacy. Men who request screening should be given information about the risks and benefits of early detection and treatment

Veterans Administration

Discuss the risks and benefits of prostate cancer screening, including PSA testing, with men over age 50; however, no specific recommendation for routine screening is indicated (Wilson and Kizer, 1998)

NOTE: DRE = digital rectal exam; PSA = prostate-specific antigen; TRUS = transrectal ultrasound.

Measuring outcomes also has limitations in prostate cancer since the illness often progresses very slowly, so that long follow-up times are necessary to show differences in survival or disease progression. Differences in rates of recurrence or survival may be a result of treatment, but if treatment is not proven to be efficacious, then observed differences in outcomes across providers may simply reflect differences in patient selection.

Diagnostic Evaluation

Clinical staging is done using all information available prior to primary treatment, including digital rectal examination (DRE), imaging, and biopsy results (American Joint Committee on Cancer, 1997). Clinical staging of prostate cancer may be reported using one of two systems: modified American staging, or TNM (tumor-node-metastasis), or American Joint Committee on Cancer staging. Current methods for clinical staging may result in a substantial proportion of cases being understaged (up to 59 percent), with a smaller proportion being over-staged (about 5 percent) (Bostwick et al., 1994). Men with regional or metastatic prostate cancer should not have radical prostatectomy (see below for further discussion of appropriate care for advanced disease), and there is the potential for inappropriate surgery if the cancer is under-



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