Clinical practice. Screening for prostate cancer.

Abstract

T h e n e w e ng l a n d j o u r na l o f m e dic i n e n engl j med 365;21 nejm.org november 24, 2011 2013 This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author's clinical recommendations. A 50-year-old, non-Hispanic white man comes for a new-patient appointment and wants to discuss prostate-cancer screening. He has no family history of prostate cancer and says that he does not have any lower urinary tract symptoms. What would you advise? The Cl inic a l Probl em Prostate cancer is the most frequently diagnosed cancer other than skin cancer and the second leading cause of death from cancer in men in the United States. 1 In 2011, prostate cancer is expected to be diagnosed in an estimated 240,000 men and to cause nearly 34,000 deaths. 1 After peaking in the early 1990s, by 2007 the age-adjusted incidence of prostate cancer had declined to 165.8 cases per 100,000 men and mortality rates had declined to 23.5 deaths per 100,000 men 2 (Fig. 1). Between 1999 and 2006, at the time of diagnosis, about 80% of prostate cancers were clinically confined to the prostate, and only 4% had metastasized. 2 The strongest risk factors for prostate cancer are older age, a positive family history , and black race. The median age at diagnosis is 67 years, and the median age at death is 81 years. 2 The risk of prostate cancer is two times as high among patients who have a first-degree relative with a prostate-cancer diagnosis as among patients who do not have a first-degree relative with this diagnosis. 3 Black men have the highest incidence rate of prostate cancer in the United States and are more likely to receive a diagnosis of prostate cancer at an advanced stage than men in any other racial or ethnic group. 2 In the United States, approximately 90% of prostate cancers are detected by means of screening. 4 After the introduction of prostate-specific antigen (PSA) testing, the lifetime risk of receiving a diagnosis of prostate cancer nearly doubled, increasing from approximately 9% in 1985 5 to 16% in 2007. 2 The great majority of men with a diagnosis of prostate cancer die from other causes. Autopsy series suggest that 30% of men older than 50 years of age and 70% of those older than 70 years of age have occult prostate cancer. 6 An analysis of data from the Surveillance, Epidemiology, and End Results (SEER) registry and from Medicare claims evaluated outcomes of almost 90,000 older men who received a diagnosis of early-stage prostate cancer between 1992 and 2002 and who were cared for without attempted curative therapy. 7 The 10-year risk of death from prostate cancer ranged from approximately 8% among men with well-differentiated tumors to 26% among those with poorly differentiated tumors. The 10-year risks of death from competing causes were consistently nearly 60%, regardless of the tumor grade.