Prostate Cancer Screening

Prostate cancer is a challenge in clinical care because 1 in every 6 men will be diagnosed with it in his lifetime but only 1 in 29 will die of it.11 Therefore, prostate cancer will not affect the life expectancy of many men diagnosed with the disease, even if they were never screened. Because it is impossible for an individual to know the effect of the diagnosis on his life expectancy, many men diagnosed with prostate cancer overestimate the benefit they gain from screening.1,142 A smaller proportion (48%) of men who went untreated for prostate cancer were satisfied with their therapy compared with men treated with androgen (63%), radiation (70%), or radical prostatectomy (59%).143 Although individuals may be satisfied with therapy, its effect has implications for morbidity and quality of life for those who are told they have the disease.1,144

Epidemiology and Natural History

In 2004, an estimated 230,110 new cases of prostate cancer were diagnosed in the United States and 29,900 men will have died of the disease.22,25 The overall incidence peaked in 1992 at about 230 in 100,000 men, but the rate has dropped since that time to the current rate of about 173 in 100,000.25 The incidence in Caucasian-Americans is lower (168 in 100,000) than it is among African-Americans (277 in 100,000), as is the mortality (30 in 100,000 versus 73 in 100,000). Overall, prostate cancer mortality has been falling since 1991, but the reason is not clear. Some have attributed the reduction to increased screening145 but others conclude that cannot be the explanation because the decline is disproportionate to the change in incidence and too early in relation to increased use of prostate screening tests.146,147 Prostate cancer is a slow-growing tumor, with a lead time ranging from 5 to 11 years depending upon what test and criteria are used to determine a positive screen.148 Mortality differences would therefore not be expected to closely follow increases in screening.

Screening Tests

Prostate-specific antigen (PSA) is an organ-specific protein secreted by the luminal epithelial cells of the prostatic ducts, acini, and periurethral glands. It may be found floating free or bound to a complex of proteins.149 Levels of PSA are measured in blood and are elevated by benign prostatic hypertrophy, inflammation, and the presence of neoplastic prostatic tissue (Table 24.7). Recent work suggests that measuring PSA bound in a protein matrix (cPSA) may be more specific than measuring serum totals.149 In practice, digital rectal examination (DRE) and transrectal ultrasound are often conducted before to PSA testing, but this does not cause increased serum PSA levels.150 A positive test for prostate cancer is generally

TABLE 24.6. Evidence for the efficacy of colorectal cancer screening.

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