Prostate Cancer Screening Page 1 of 5
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.
The objective of this guideline is to maximize the detection of CLINICALLY SIGNIFICANT prostate cancer; it does not address whether or not early detection is
appropriate. An inherent result of increasing overall prostate detection is the discovery of both clinically significant and clinically insignificant prostate cancers, as
they are currently defined. Due to the unique biology of prostate cancer, over-treatment is of concern because the results can potentially impact quality of life. The
value of prostate cancer screening is controversial. These general guidelines are based on the majority recommendations according to patient preference and expert
opinion at the University of Texas MD Anderson Cancer Center. They are intended for those men who elect to undergo early detection (after informed consent).
Department of Clinical Effectiveness V4
Copyright 2023 The University of Texas MD Anderson Cancer Center Approved by the Executive Committee of the Medical Staff on 07/18/2023
Prostate Cancer Screening Page 2 of 5
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.
EVALUATION SCREENING FOLLOW-UP
PSA < 1 ng/mL and Repeat testing at 2-4 year intervals6
DRE normal (if done)
History and physical including:
● Family history PSA 1-3 ng/mL7 and
● Medications
Repeat testing at 1-2 year intervals6
Age1,2,3 45-75 years DRE normal (if done)
● History of prostate disease Start risk and benefit
and screening, including discussion about
prior prostate specific antigen offering prostate PSA > 3 ng/mL5,7or
(PSA) and/or isoforms, screening3,4: very suspicious DRE Refer for diagnostic evaluation8
5
exams and biopsies ● Baseline PSA
● Race
1 ● Strongly consider
● Family or personal history of baseline digital
rectal examination PSA < 4 ng/mL,
BRCA1/2 mutations2. Repeat testing in select patients at
(DRE) DRE normal (if done), and
Consider genetic testing if
no other indications for 2-4 year intervals
there is more than one first
Age > 75 years, in select biospy
degree relative with prostate
cancer. patients9
PSA > 4 ng/mL5 or very
Refer for diagnostic evaluation8
suspicous DRE
See Footnotes on Page 3
Department of Clinical Effectiveness V4
Copyright 2023 The University of Texas MD Anderson Cancer Center Approved by the Executive Committee of the Medical Staff on 07/18/2023
Prostate Cancer Screening Page 3 of 5
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.
FOOTNOTES
1
Black/African-American men have a higher incidence of prostate cancer, increased prostate cancer mortality, and earlier age of diagnosis compared to Caucasian-American men. This is
attributable to a greater risk of developing preclinical prostate cancer and a higher likelihood that a preclinical tumor will spread. Consequently, it is reasonable for Black/African-American
men to begin discussing PSA screening with their providers at 40 years of age and to consider screening at annual intervals rather than every other year.
2
If there is a known or suspected cancer susceptibility gene mutation, referral to a cancer genetics professional is recommended. BRCA1/2 pathogenic mutation carriers are associated with an
increased risk of prostate cancer before age 65 years, and prostate cancer in men with germline BRCA2 mutations occurs earlier and is more likely to be associated with prostate cancer
mortality. Information regarding BRCA1/2 gene status should be used as part of the discussion about prostate cancer screening.
3
May begin at 40 years of age for men with more than one first-degree relative who had prostate cancer at an early age
4
The best evidence supports the use of serum PSA for the early detection of prostate cancer. Digital rectal exam (DRE) should not be used as a stand-alone test, but should be performed in
those with an elevated serum PSA. DRE may be considered as a baseline test in all patients as it may identify high-grade cancers associated with “normal” serum PSA values. Consider
referral for biopsy if DRE is very suspicious. Medications such as 5α-reductase inhibitors (finasteride and dutasteride) are known to decrease PSA by approximately 50%. PSA values in these
men should be corrected accordingly.
5
Repeat PSA testing if PSA is elevated. In people with a newly elevated PSA, it will return to a normal level in 20-40% upon rechecking. Depending on the clinical circumstances related to suspicion
of prostate cancer versus other conditions that could cause a spurious rise in PSA the repeat test should be performed within 8 weeks.
6
Men age greater than or equal to 60 years with serum PSA less than 1.0 ng/mL have a very low risk of metastases or death due to prostate cancer and may not benefit from further testing.
A PSA cut point of 3.0 ng/mL at age 75 years also carries a low risk of poor outcome.
7
The reported median PSA values for men aged 40-49 year range from 0.5-0.7 ng/mL, and the 75th percentile values range from 0.7-0.9 ng/mL. Therefore, the PSA value of 1.0 ng/mL
selects for the upper range of PSA values. Men who have a PSA above the median for their age group are at a higher risk for prostate cancer and for the aggressive form of the disease.
The higher above the median, the greater the risk.
8
For diagnostic evaluation refer to NCCN Prostate Cancer Early Detection guideline
9
Testing above 75 years of age should be done with caution and only in very healthy men with little or no comorbidity as a large proportion may harbor cancer that would be unlikely to affect
their life expectancy, and screening in this population would substantially increase rates of over-detection. However, a clinically significant number of men in this age group may present with
high-risk cancers that pose a significant risk if left undetected until signs or symptoms develop. Consider omitting PSA testing in men above the age of 75 years as very few will benefit.
Department of Clinical Effectiveness V4
Copyright 2023 The University of Texas MD Anderson Cancer Center Approved by the Executive Committee of the Medical Staff on 07/18/2023
Prostate Cancer Screening Page 4 of 5
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.
SUGGESTED READINGS
American Cancer Society. (2010). Early Detection Prostate Cancer ACS: Informed Decision Making Core Elements. Retrieved from [Link]
cancer-society-prevention-early-detection-guidelines/[Link]
Brooks, D. D., Wolf, A., Smith, R. A., Dash, C., & Guessous, I. (2010). Prostate Cancer screening 2010: Updated recommendations from the American Cancer Society. Journal of the National
Medical Association, 102(5), 423-9. doi:10.1016/S0027-9684(15)30578-2
Eastham, J. A., Riedel, E., Scardino, P. T., Shike, M., Fleisher, M., Schatzkin, A., … Begg, C. B. (2003). Variation of serum prostate-specific antigen levels: An evaluation of year-to-year
fluctuations. JAMA, 289(20), 2695-2700. doi:10.1001/jama.289.20.2695
Halpern, J. A., Shoag, J. E., Mittal, S., Oromendia, C., Ballman, K. V., Hershman, D. L., … Hu, J. C. (2017). Prognostic significance of digital rectal examination and prostate specific antigen
in the prostate, lung, colorectal and ovarian (PLCO) cancer screening arm. The Journal of Urology, 197(2), 363-368. doi:10.1016/[Link].2016.08.092
Hawken, S. R., Auffenberg, G. B., Miller, D. C., Lane, B. R., Cher, M. L., Abdollah, F., … Ghani, K. R. (2017). Calculating life expectancy to inform prostate cancer screening and
treatment decisions. BJU International, 1-3, doi:10.1111/bju.13812
National Comprehensive Cancer Network. (2022). Prostate Cancer Early Detection (NCCN Guideline Version 1.2022). Retrieved from [Link]
[Link]
Schaeffer, E. M., Carter, H. B., Kettermann, A., Loeb, S., Ferrucci, L., Landis, P., … Metter, E. J. (2009). Prostate specific antigen testing among the elderly – when to stop?
The Journal of Urology, 181(14), 1606-1614, doi:10.1016/[Link].2008.11.117
Social Security Administration. (n.d.). Actuarial Life Table. Retrieved from [Link]
U.S. Preventive Services Task Force. (2018). Prostate Cancer: Screening. Retrieved from [Link]
Wolf, A. M. D., Wender, R. C., Etzioni, R. B., Thompson, I. M., D'Amico, A. V., Volk, R. J., … DeSantis, C. (2010). American Cancer Society guideline for the early detection of prostate
cancer: Update 2010. CA: A Cancer Journal for Clinicians, 60(2), 70-98. doi:10.3322/caac.20066
Department of Clinical Effectiveness V4
Copyright 2023 The University of Texas MD Anderson Cancer Center Approved by the Executive Committee of the Medical Staff on 07/18/2023
Prostate Cancer Screening Page 5 of 5
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.
DEVELOPMENT CREDITS
This screening algorithm is based on majority expert opinion of the Prostate Screening work group at the University of Texas MD Anderson Cancer Center.
It was developed using a multidisciplinary approach that included input from the following:
Core Development Team Leads
Therese Bevers, MD (Clinical Cancer Prevention)
Joyce Dains, DrPH, JD, RN, FNP-BC (Nursing)
John Davis, MD (Urology)
Christopher Logothetis, MD (Genitourinary Medical Oncology)
Curtis Pettaway, MD (Urology)
John Ward, MD (Urology)
Workgroup Members
Powel Brown, MD (Clinical Cancer Prevention)
Olga N. Fleckenstein, BS♦
Ernest Hawk, MD (Clinical Cancer Prevention)
Thoa Kazantsev, MSN, RN, OCN♦
♦
Clinical Effectiveness Development Team
Department of Clinical Effectiveness V4
Copyright 2023 The University of Texas MD Anderson Cancer Center Approved by the Executive Committee of the Medical Staff on 07/18/2023