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## Complete Summary

#### GUIDELINE TITLE

Screening for prostate cancer in U.S. men: ACPM position statement on
preventive practice.

#### BIBLIOGRAPHIC SOURCE(S)

Lim LS, Sherin K, ACPM Prevention Practice Committee. Screening for
prostate cancer in U.S. men: ACPM position statement on preventive
practice \[erratum appears in Am J Prev Med 2008 May;34(5):454\]. Am J
Prev Med 2008 Feb;34(2):164-70. \[60 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=18201648)

#### GUIDELINE STATUS

This is the current release of the guideline.

This summary updates a previous version: Ferrini R, Woolf SH. American
College of Preventive Medicine Practice Policy: screening for prostate
cancer in American men. Am J Prev Med 1998 Jul;15(1):81-4.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Prostate cancer

#### GUIDELINE CATEGORY

Prevention\
Screening

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Oncology\
Preventive Medicine\
Urology

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

To review the efficacy of digital rectal exam (DRE) and
prostate-specific antigen (PSA) for prostate cancer screening found in
the medical literature prior to July 2007

#### TARGET POPULATION

American men

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Screening for prostate cancer:

    -   Digital rectal examination (DRE)

    -   Measurement of the serum tumor marker prostate specific antigen
        (PSA)

2.  Counseling patients on risks and benefits of screening

#### MAJOR OUTCOMES CONSIDERED

-   Age-adjusted incidence of prostate cancer

-   Morbidity and mortality due to prostate cancer

-   Sensitivity, specificity, and positive predictive values of
    screening tests for prostate cancer

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Subjective Review

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

The cost effectiveness of screening for prostate cancer has been
difficult to calculate due to the lack of data on screening
effectiveness. However, the estimated cost of treating prostate cancer
in the U.S. ranged from US\$1.72 billion to US \$4.75 billion (1990
costs). Implementing a national screening program using
prostate-specific antigen (PSA) and digital rectal examination (DRE) for
men aged 50 to 69 years is estimated to cost between \$17.6 billion and
\$25.7 billion in the first year.

#### METHOD OF GUIDELINE VALIDATION

Comparison with Guidelines from Other Groups\
Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Guidelines/recommendations from the following groups were reviewed:

-   American Urological Association

-   American Cancer Society

-   American Academy of Family Physicians

-   Institute for Clinical Systems Improvement

-   U.S. Preventive Services Task Force

-   American College of Physicians

-   Canadian Task Force on the Periodic Health Examination

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The American College of Preventive Medicine (ACPM) concludes that there
is currently insufficient evidence to recommend routine population
screening with digital rectal examination (DRE) or prostate-specific
antigen (PSA), concurring with the Unites States Preventive Services
Task Force (USPSTF) recommendation. The College is in agreement with the
American College of Physicians (ACP) that men should be given
information about the potential benefits and harms of screening and
limits of current evidence in order to make an informed decision about
screening. Discussion about screening should occur annually, during the
routine periodic examination, or in response to a request by the
patient. The effectiveness of prostate cancer screening is questionable
in elderly men with competing co-morbidities and men with life
expectancies of less than 10 years. Ultimately, a man should be allowed
to make his own choice about screening, in consultation with his
physician, taking into consideration personal preferences and life
expectancy. If the patient prefers to defer to the clinician or is
unable to make a decision regarding screening, then testing should not
be offered as long as the patient understands the benefits, potential
limitations, and adverse effects associated with screening. Key points
that should be communicated during the patient encounter regarding
prostate cancer screening are listed in the table below.

Pending resolution of ongoing controversies, screening for prostate
cancer among African-American men and those with a family history of
prostate cancer has the potential to detect treatable forms of disease
that are more likely to occur in these groups than in the general
population. While the usual age for prostate cancer screening is between
50 to 70 years in average risk men, it has been suggested that those who
are at high risk may benefit from earlier screening beginning at age 45,
while higher-risk men (those with two or more first-degree relatives
with prostate cancer before age 65) be screened at age 40. Granted that
prostate cancer is more likely to be found in high-risk men, issues
pertaining to tumor grade have yet to be resolved (that is, optimal
grade of tumor that a screening test should detect to confer a benefit
in survival or morbidity), and there is still no evidence establishing
effectiveness of screening in high-risk men. In the meantime, further
studies are needed to establish the efficacy and optimal age at which
prostate cancer screening should be initiated in these high-risk
population groups.

+-----------------------------------------------------------------------+
|   ------------------------------------------------------------------  |
|   **Table: Benefits and                                               |
|   Limitations of PSA                                                  |
|   Screening for Prostate                                              |
|   Cancer: Key Points for                                              |
|   Patient Discussion**                                                |
|   ----------------------- ------------------------------------------  |
|   **Benefits of           **Limitations of Screening**                |
|   Screening**                                                         |
|                                                                       |
|   Early detection and     Survival benefit from prostate cancer       |
|   treatment of            screening has not been demonstrated in      |
|   potentially curable     rigorous trials.                            |
|   stage of prostate                                                   |
|   cancer (i.e., better                                                |
|   chances of survival                                                 |
|   with localized                                                      |
|   disease).                                                           |
|                                                                       |
|   Reassurance of being at False positive result may lead to           |
|   low risk for prostate   increased anxiety and having to experience  |
|   cancer.                 the discomfort and possible complications   |
|                           associated with biopsy (e.g., pain,         |
|                           hematospermia/hematuria, and infection).    |
|                                                                       |
|   PSA can be obtained     Prostate cancer may be slow growing and     |
|   with a simple blood     may never advance or progress to cause      |
|   test and is widely      significant disease or death. Treatment     |
|   available.              can cause both short- and long-term side    |
|                           effects (e.g., pain, urinary incontinence,  |
|                           and impotence).                             |
|                                                                       |
|                           False reassurance from a normal test        |
|                           (false negative), leading to a delayed      |
|                           diagnosis of prostate cancer.               |
|   ------------------------------------------------------------------  |
+-----------------------------------------------------------------------+

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence supporting the recommendations is not specifically
stated.

In general, the recommendations are based on a review of the literature
prior to July 2007 and recommendations from other groups.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Benefits of screening include early detection and treatment of
potentially curable stage of prostate cancer (i.e., better chances of
survival with localized disease) and reassurance of being at low risk of
cancer.

**Subgroups Most Likely to Benefit**

Men with a first-degree relative (e.g., father, brother) with prostate
cancer and African-American men are at higher risk of both developing
and dying from prostate cancer.

#### POTENTIAL HARMS

Both screening and treatment can be harmful:

-   A false positive result may lead to increased anxiety and having to
    experience the discomfort and possible complications associated with
    biopsy (e.g., pain, hematospermia/hematuria, and infection)

-   Prostate cancer may be slow growing and may never advance or
    progress to cause significant disease or death. Treatment can cause
    both short- and long-term side effects (e.g., pain, urinary
    incontinence, and impotence).

-   Men who received false-positive prostate-specific antigen test
    results reported having thought and worried more about prostate
    cancer despite receiving a negative follow-up (prostate biopsy)
    result. Thus screening may cause undesirable mental health
    consequences.

-   False reassurance from a normal test (false negative), leading to a
    delayed diagnosis of prostate cancer.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Lim LS, Sherin K, ACPM Prevention Practice Committee. Screening for
prostate cancer in U.S. men: ACPM position statement on preventive
practice \[erratum appears in Am J Prev Med 2008 May;34(5):454\]. Am J
Prev Med 2008 Feb;34(2):164-70. \[60 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=18201648)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1998 (revised 2008 Feb)

#### GUIDELINE DEVELOPER(S)

American College of Preventive Medicine - Medical Specialty Society

#### SOURCE(S) OF FUNDING

American College of Preventive Medicine

#### GUIDELINE COMMITTEE

ACPM Prevention Practice Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Authors*: Lionel S. Lim, MD, MPH, FACP; Kevin Sherin, MD, MPH, FACPM

*Committee Members*: Gershon H. Bergeisen, MD, MPH; Michael T. Compton,
MD, MPH; V. James Guillory, DO, MPH, FACPM (Chair); Doug I. Hammer, MD,
MPH, DrPH; Joylene John-Sowah, MD, MPH; Steven Jonas, MD, MPH
(Consultant); Elizabeth Kann, MD, MPH; Ronit B. Katz, MD, FACPM; Robin
McFee, DO, MPH, FACPM; Elaine S. Perry, MD, MS; Jennifer E. Rogers, MPH
(Staff); and Michele A. Surricchio, MPH, CHES (Staff)

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

No financial disclosures were reported by the authors of this paper.

#### GUIDELINE STATUS

This is the current release of the guideline.

This summary updates a previous version: Ferrini R, Woolf SH. American
College of Preventive Medicine Practice Policy: screening for prostate
cancer in American men. Am J Prev Med 1998 Jul;15(1):81-4.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American College of Preventive Medicine (ACPM) Web
site](http://www.acpm.org/ProstateScreening_AJPM.pdf).

An erratum to this guideline has been published and is available from
the [American Journal of Preventive Medicine Web
site](http://www.ajpm-online.net/article/S0749-3797(08)00167-0/fulltext).

Print copies: Available from ACPM, 1307 New York Ave, N.W., Suite 200,
Washington, DC 20005-5603.

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on September 1, 1998. The information
was verified by the guideline developer on December 1, 1998. This NGC
summary was updated by ECRI Institute on June 2, 2008. The updated
information was verified by the guideline developer on June 23, 2008.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008