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According to the Canadian Cancer Society, prostate cancer is the most common cancer to affect men in Canada. One in nine men will be diagnosed with the disease in their lifetime. Risk factors for prostate cancer are age (i.e. over 50, primarily 65+), a first degree relative with prostate cancer, African descent and being overweight. Screening increases the likelihood of prostate cancer being detected at an early stage―when there are more treatment options and the chance of survival is highest.
Here are some resources on prostate cancer selected by Joule’s Ask a Librarian team using a variety of tools included with CMA membership.
Clinical summary from DynaMed
Prostate Cancer Screening
Who and when to screen
- The decision to offer testing for prostate cancer should be based on each individual’s estimated life expectancy as well as the probability that a clinically significant cancer may be present.
- Engage men in shared decision-making for an informed choice regarding prostate cancer screening based on benefits and harms of prostate-specific antigen (PSA) testing (Strong recommendation).
- For men with average risk, age for prostate cancer screening based on shared decision-making differs among professional organizations:
- age 45-75 years according to the National Comprehensive Cancer Network (NCCN)
- age 50-69 years according to the American College of Physicians (ACP)
- age 55-69 years according to the American Urological Association (AUA) and the United States Preventive Services Task Force (USPSTF)
- age 50 years according to the American Cancer Society (ACS)
- age 50 also for men at elevated risk not of African American ethnicity and without family history of prostate cancer according to the European Association of Urology (EAU)
- For men with high risk (including African American men, men with germline BRCA1 or BRCA2 mutation, or men with family history in first-degree relatives), start prostate cancer screening based on shared decision-making at age ≥ 40 years (Strong recommendation)
- For men ≥ 70 years old or with life expectancy < 10-15 years, prostate cancer screening is not recommended (Strong recommendation).
- For men < 40 years old, prostate cancer screening is not recommended (Strong recommendation).
23 Aug 2019
Decision aids may not affect screening discussion rates or decision to undergo screening in men considering prostate cancer screening (JAMA Intern Med 2019 Jun 24 early online).
23 Aug 2019
Decision aids may slightly increase knowledge and reduce decisional conflict in men considering prostate cancer screening (JAMA Intern Med 2019 Jun 24 early online).
9 May 2019
Review of prostate cancer screening (Prim Care 2019 Jun).
5 Apr 2019
PSA screening may slightly reduce prostate cancer mortality with no reduction of overall mortality over 16 years of follow-up (Eur Urol 2019 Feb 26 early online).
Clinical summary from Essential Evidence Plus
Essential Evidence Plus is an evidence-based point of care tool with access to over 13,000 topics, guidelines, abstracts and summaries. For a synopsis of new evidence reviewed by the Essential Evidence Plus editorial team, subscribe to the POEMs daily newsletter.
- Overall bottom line: Prostate cancer screening is inexact and in its current state provides a small cancer-specific mortality benefit (NNT ~800 over 13 years) and reduction in metastatic disease (3 per 1000 person-years), and no all-cause mortality benefit. There are significant harms including incontinence and sexual dysfunction for many treated men.
- Patients and physicians should engage in shared decision making before undertaking screening, and if undertaken should be limited to healthy men age 55 to 69 who fully understand the potential harms and benefits.
- Initial therapy for localized disease can be radical prostatectomy, radiotherapy, or active surveillance, with the potential harms of treatment varying but all being similarly effective in terms of mortality.
Read more via Essential Evidence Plus (CMA members only)
Synopsis of clinical studies in POEMs by Essential Evidence Plus:
POEM: Prostatectomy reduces mortality compared with no surveillance in men with T2 cancer who presented with symptoms
In men with symptomatically detected prostate cancer, does radical prostatectomy reduce mortality compared with watchful waiting?
Although at first glance the results of this trial may appear to strengthen the argument in favor of prostate cancer screening using a prostate-specific antigen (PSA) test, it is important to clarify that this was not a screening study. Also, the patients had a much higher PSA result (mean 13 vs median 4.8 ng/mL) and stage (mostly T2 vs mostly T1c) than patients in the recent ProtecT trial. Also, the "watchful waiting" in this study was not the same as the contemporary practice of active surveillance. This study does tell us that for men presenting because of symptoms, who are diagnosed with stage T2 prostate cancer, and have a fairly high PSA level, surgery reduces mortality compared with doing nothing.
Bill-Axelson A, Holmberg L, Garmo H, et al. Radical prostatectomy or watchful waiting in prostate cancer: 29-year follow-up. N Engl J Med 2018;379(24):2319-2329.
Book Chapters via ClinicalKey (CMA members only):
ClinicalKey drives better care by delivering fast, concise answers, and deep access to evidence whenever, wherever you need it. ClinicalKey includes access to 1,000+ textbooks, 600 full-text journals, images, videos and customizable patient handouts across 30+ medical specialties
- Prostate Cancer, in Ferri's Clinical Advisor 2020, 1150-1154.e3
- Hormone-Responsive Cancers, in Yen & Jaffe's Reproductive Endocrinology, Chapter 29, 717-741.e8
- Prostate Cancer, in Goldman-Cecil Medicine, 191, 1337-1341.e2
Articles via CMAJ:
Douglas C. Cheung and Antonio Finelli, CMAJ October 28, 2019 191 (43) E1177-E1178
Cancer: prostate – CMAJ Collection
Clinical Practice Guidelines via CPG Infobase:
CPG Infobase contains approximately 1,200 evidence-based Canadian clinical practice guidelines (CPGs) developed or endorsed by authoritative medical or health organizations in Canada.
- Canadian Urological Association recommendations on prostate cancer screening and early diagnosis by Canadian Urological Association
- Referral of suspected prostate cancer by family physicians and other primary care providers by Cancer Care Ontario's Program in Evidence-based Care
Canadian Clinical practice guidelines on Prostate Cancer in the CPG Infobase.
Drug Information via CPS online and on the RxTx app (CMA members only):
CPS offers 2000+Canadian product monographs for drugs, vaccines and natural health products that are developed by manufacturers, approved by Health Canada and optimized by CPhA editors
Search “prostate cancer” in the CPS on the RxTx app to find related drug monographs that provide information regarding dosage, adverse effects, drug interactions and action and clinical pharmacology.
The CPS Online includes patient handouts. Search “prostate cancer” and select “Information for patients” to access handouts on a number of drugs for this indication.
Free information sources
Prostate cancer – Canadian Cancer Society
Prostate cancer treatment options – Prostate Cancer Canada
Early versus deferred standard androgen suppression therapy for advanced hormone‐sensitive prostate cancer – Cochrane Review 11 June 2019 Conclusions changed (summary only)
Recent trends in prostate cancer in Canada, Apr 2019 – Statistics Canada
Need more information or have a more focused clinical question on prostate cancer (or any other clinical topic of interest)? Contact the Ask a Librarian team to request a literature search.
This material is for informational purposes only. It is not intended to be a substitute for professional medical advice and should not be relied on as health or personal advice. The opinions stated by the authors are made in a personal capacity and do not necessarily reflect those of the Canadian Medical Association and its subsidiaries including Joule. Feel passionate about physician-led innovation? Please connect with us at email@example.com.
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