美国泌尿学会2013年前列腺癌早期筛查指南

1、不推荐对40岁以下男性行常规PSA筛查（证据级别C级）。此年龄范围的人群前列腺癌临床检出率较低，没有证据说明筛查获益，风险较其他年龄组相当。

2、不推荐对发生前列癌一般风险的40-54岁的人群行常规PSA筛查（证据级别C级）。对于55岁以下前列腺癌高风险的人群（如有阳性家族史，非洲裔美国人），是否需要前列腺癌筛查需要个体化决策。

3、对于55-69岁人群，PSA筛查需衡量风险和获益。获益为筛查10年可以降低千分之一的死亡率，风险则为检查和治疗的潜在危害。基于此原因，专家组推荐对于55-69岁患者考虑行PSA筛查时，需要考虑患者的价值观和意愿（证据级别B级）。PSA筛查获益最大的是55-69岁人群。

4、为了减少检查的危害，对于被检者参与临床决策并决定要行筛查者，建议每2年或更长时间行一次常规检查。不推荐每年一次。每2年一次比每年一次获益更多，且减少了过度诊断和假阳性的概率（证据级别C级）。另外，再次筛查的间隔时间也要根据基线PSA水平个体化决策。

5、专家组不推荐对70岁以上人群或预计生存期少于10-15年的人群常规筛查PSA（证据级别C级）。部分大于70岁但健康状况良好的人群可能筛查中获益。

与前列腺癌相关的拓展阅读：

• CEBP：睡眠问题或增加前列腺癌风险
• Oncogenesis：揭示维生素A降低前列腺癌干细胞侵袭性机制
• Radiother Oncol：放疗在乳腺癌和前列腺癌患者中的使用有上升趋势
• Nature Communications:前列腺癌干细胞发生DNA重排导致癌症复发
• JCO:首个前列腺癌预后遗传因子
• JCO：zibotentan联合多西他赛不能改善转移性去势抵抗前列腺癌患者生存
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Guideline Statements
Guideline Statement 1: The Panel recommends against PSA screening in men under age 40 years. (Recommendation; Evidence Strength Grade C)
•In this age group there is a low prevalence of clinically detectable prostate cancer, no evidence demonstrating benefit of screening and likely the same harms of screening as in other age groups.
Guideline Statement 2: The Panel does not recommend routine screening in men between ages 40 to 54 years at average risk. (Recommendation; Evidence Strength Grade C)
•For men younger than age 55 years at higher risk (e.g. positive family history or African American race), decisions regarding prostate cancer screening should be individualized.
Guideline Statement 3: For men ages 55 to 69 years the Panel recognizes that the decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality in 1 man for every 1,000 men screened over a decade against the known potential harms associated with screening and treatment. For this reason, the Panel strongly recommends shared decision-making for men age 55 to 69 years that are considering PSA screening, and proceeding based on a man’s values and preferences. (Standard; Evidence Strength Grade B)
•The greatest benefit of screening appears to be in men ages 55 to 69 years.
Guideline Statement 4: To reduce the harms of screening, a routine screening interval of two years or more may be preferred over annual screening in those men who have participated in shared decision-making and decided on screening. As compared to annual screening, it is expected that screening intervals of two years preserve the majority of the benefits and reduce overdiagnosis and false positives. (Option; Evidence Strength Grade C)
•Additionally, intervals for rescreening can be individualized by a baseline PSA level.
Guideline Statement 5: The Panel does not recommend routine PSA screening in men over age 70 years or any man with less than a 10 to 15 year life expectancy. (Recommendation; Evidence Strength Grade C)
•Some men over age 70 years who are in excellent health may benefit from prostate cancer screening.
Purpose
This guideline addresses prostate cancer early detection for the purpose of reducing prostate cancer mortality with the intended user as the urologist. This document does not make a distinction between early detection and screening for prostate cancer. Early detection and screening both imply detection of disease at an early, pre-symptomatic stage when a man would have no reason to seek medical care –an intervention referred to as secondary prevention.1 In the US, early detection is driven by prostate specific antigen (PSA)-based screening followed by prostate biopsy for diagnostic confirmation. While the benefits of PSA-based prostate cancer screening have been evaluated in randomized-controlled trials, the literature supporting the efficacy of DRE, PSA derivatives and isoforms (e.g. free PSA, -2proPSA, prostate health index, hK2, PSA velocity or PSA doubling time) and novel urinary markers and biomarkers (e.g. PCA3) for screening with the goal of reducing prostate cancer mortality provide limited evidence to draw conclusions. While some data suggest use of these secondary screening tools may reduce unnecessary biopsies (i.e. reduce harms) while maintaining the ability to detect aggressive prostate cancer (i.e. maintain the benefits of PSA screening), more research is needed to confirm this. However, the likelihood of a future population-level screening study using these secondary screening approaches is highly unlikely at least in the near future. Therefore, this document focuses only on the efficacy of PSA screening for the early detection of prostate cancer with the specific intent to reduce prostate cancer mortality and not secondary tests often used after screening to determine the need for a prostate biopsy or a repeat prostate biopsy (e.g., PSA isoforms, PCA3, imaging)....