Vol.2, No.10, 1179-1183 (2010) Health
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Prostate cancer screening: a primary care survey
Samuel Deem1*, Brian DeFade1, Josh Lohri1, James P. Tierney1, Asmita Modak2, Mary Emmett2
1Department of Urology, Charleston Area Medical Center, Charleston, WV, USA; *Corresponding Author: deemsg@musc.edu
2Research & Statistics, CAMC Health Education & Research Institute, Charleston, WV, USA
Received 12 August 2010; revised 18 August 2010; accepted 25 August 2010.
Prostate cancer is the most common intrinsic
cancer in men and the 2nd most common cause
of cancer related death in men over fifty years of
age. The benefit of early screening for prostate
cancer is yet to be proven. Multiple organizati-
ons currently offer recommendations regarding
prostate cancer screening. Prostate Specific An-
tigen (PSA) testing was introduced into widesp-
read use in the late 80’s and its role in screening
is debatable. We surveyed by mail every primary
care physician in West Virginia who has a state
license. Results from 438 respondents indicated
that the American Cancer Society (ACS) guide-
lines were most commonly used and that PSA
testing does seem to be a good screening test.
We present the results and discuss the different
points of view regarding prostate cancer scree-
Keywords: Prostate; Cancer; Screening; PSA;
Guidelines; Survey
Prostate cancer is the most common form of non-skin
cancer among men in the United States. It is the second
leading cause of cancer deaths in American men, after
lung cancer, and the sixth leading cause of death overall
for men in this country [1]. American men have a 1 in 6
chance of developing prostate cancer in their lifetime and
a 1 in 30 chance of dying from prostate cancer. Most of
the deaths from prostate cancer are related to advanced
disease that could have potentially been prevented with
better screening practices. However, multiple non-urolo-
gy driven groups propose less or no screening for pros-
tate cancer. Continuous advances have provided a new
understanding of the diagnosis, staging, and treatment of
metastatic and advanced prostate cancer and the poten-
tial benefits of early screening programs. Despite these
ongoing improvements, prostate cancer is unlike any ot-
her tumor, the natural history is that it will progress over
time but the unanswered question is over what period of
Some prostate cancer would never have been detected
without screening using the PSA. Controversy exists be-
tween physicians worldwide about the pros and cons of
recommending early screening. Screening programs have
been shown to diagnose prostate cancer earlier but no
evidence currently can definitively prove a decrease in
mortality influenced by screening. Declining mortality
and observed trends of lower clinical and pathological
stages of the tumor where screening is common provides
inferential evidence that screening is possibly beneficial
[2]. It has been estimated that only 54% of men between
50 and 69 years of age have had a PSA test for screening
in the previous year [3].
Recently, a decrease in prostate cancer mortality was
seen in West Virginia and in the United States [4]. It is
not clear whether PSA-based screening was responsible
for this decrease but some studies have claimed a reduc-
tion in prostate cancer mortality through PSA-based sc-
reening [5,6]. Mortality rate due to prostate cancer is
steadily declining at a rate of 3.4% per year since 1990
indicating that screening is likely beneficial with the res-
ult being earlier diagnosis of an aggressive disease [7].
Current research is investigating whether screening for
prostate cancer is the primary factor leading to this redu-
ction in death caused by the disease, but results to date
have been conflicting.
The Prostate, Lung, Colorectal and Ovarian cancer sc-
reening trial (PLCO) is a randomized, prospective, mu-
lti-center trial in the U.S. designed to determine if pros-
tate cancer screening does alter mortality compared to no
screening [8]. Early results were recently published in
the New England Journal of Medicine (NEJM) showing
no early benefit of screening for prostate cancer seen at 7
to 10 years follow-up. The results and the limitations of
the study have been discussed extensively in recent liter-
ature. Some of the criticisms include the length of foll-
ow-up being too short to show a survival benefit because
S. Deem et al. / Health 2 (2010) 1179-1183
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
prostate cancer can be an indolent disease taking several
years to become aggressive. The trial included patients
in the non-screening arm that were previously screened
prior to the trial or were screened during the trial, both of
which would include men with a lower risk of develop-
ing cancer during the trial. We all await the final results
of the trial once long term data has been collected [9].
Results of another trial, the European Randomized
Study for Screening of Prostate Cancer (ERSPC), were
published in the same issue of NEJM. The authors repo-
rted that screening reduced the rate of prostate cancer
death by 20 percent but was associated with a higher rate
of over-diagnosis. Several criticisms of this study have
been discussed and the contrast between the two trials is
alarming. Further development of the data is necessary
to draw any conclusions from either trial [10].
Another area of research interest includes both patie-
nts and health care providers’ knowledge and awareness
of prostate cancer screening. These projects will further
the efforts to develop and deliver appropriate public hea-
lth strategies for prostate cancer, and will improve the sh-
aring of screening-related information between providers
and their patients [11]. Until further data exists, we must
rely on the best evidence available, which currently wo-
uld recommend early screening for prostate cancer in a
select patient group only after a thorough discussion of
the potential risks and benefits of screening with the pa-
tient. Educating patients about all options for treatment
of prostate cancer including active surveillance may help
avoid the unnecessary treatment of some cancers while
still screening to find the aggressive types.
Our objectives with this study were first to determine
the current screening practices of primary care physic-
ians in one state (West Virginia) and then to discuss
what current best evidence would suggest.
This study was approved by the Institutional Review Bo-
ard at Charleston Area Medical Center. We present the
data that was collected from a mail survey of all physi-
cians identified as primary care practitioners through the
West Virginia Board of Medicine and the West Virginia
Board of Osteopathy. Questionnaires were mailed out in
March of 2008 with a follow-up mailing completed in
May of 2008. The questionnaire consisted of thirteen
multiple-choice questions using a standardized data col-
lection form. The questions focused on the physicians
personal practice preferences and their attitudes toward
prostate cancer screening and guidelines including the
use of PSA and digital rectal examination (DRE) for this
Statistical anaylysis was performed by CAMC Health
Education and Research Institute, Center for Health Serv-
ices and Outcomes Research. Descriptive statistics were
used. Chi squared/Fisher’s exact tests where appropriate
were used at 95% level of significance for cross tabula-
tion analysis after combining different questions. Analy-
sis was done using SAS 9.1.3.
Out of a total of one-thousand five hundred and thirty-
six (1536) questionnaires a total of 442 physicians re-
sponded to the survey. Of these, 58 had either an incor-
rect address or reported that they had retired from gen-
eral practice or practiced in a select medical specialty.
Four additional responses came in after the data were
calculated and therefore are not included in the results.
Our results are based on 380 completed questionnaires.
The guideline cited as the most used was the Ameri-
can Cancer Society (ACS) guidelines with 187 (56.5%)
respondents using this in their current practice. Only 9
(2.72%) respondents currently used the National Compr-
ehensive Cancer Network (NCCN) guidelines for pros-
tate cancer screening. Table 1 lists each guideline and
shows the percentages of respondents who indicated that
they used them. This table illustrates the percentage of
respondents who feel that PSA is a useful screening tool
for prostate cancer and compares this response to which
guideline they use. When asked about familiarity with
NCCN guidelines in regards to prostate cancer, 157
(42.9%) of the respondents were not at all familiar and
33 (9.02%) did not know about the NCCN guidelines.
Only 4 of the 33 physicians who were very familiar with
the guidelines actually based their screening on them.
Table 1. Distribution of physicians using each guideline and
the response to “Is PSA a useful screening test?” based on the
guideline used.
Is PSA useful
Undecided No Yes
Cancer Society
American Urological
Center for
Disease Control
National Comprehensive
Cancer Network
Other/(USPSTF) 26
Total 94
S. Deem et al. / Health 2 (2010) 1179-1183
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Three hundred and forty-seven (93.53%) clinicians
reported either yes or it depends when asked if they
routinely screen all men over the age of 50 for prostate
cancer. Two hundred and fifty four (68.65%) respon-
dents routinely performed a digital rectal examination
(DRE) and 308 (81.91%) routinely checked a Prostate
Specific Antigen (PSA) test in all men over the age of 50.
Figure 1 shows the results of using either a DRE or PSA
or both by those who routinely screen for prostate cancer
in men after the age of 50.
Two hundred and forty-five (245) (65.51%) clinicians
felt that the PSA is a useful screening tool for diagnosing
prostate cancer while an additional 105 (28.07%) were
uncertain. Urology consultation was most commonly
advised when a PSA value of greater than 4 was found
with 218 (59.24%) in agreement. We found that 145
(39.84%) physicians who consider the PSA to be a use-
ful screening test also feel that a PSA level greater than
4 is when to suggest a Urology consultation. The P-value
was found to be 0.0423, which means that there is a sta-
tistically significant difference between physicians con-
sidering PSA as a useful screening tool and their opinion
about advisable PSA level for referral at 95% level of
Physicians answered that age rather than guidelines is
the most common reason for recommending prostate
cancer screening as seen in Figure 2. Most physicians
(70%) were unaware of the current rise in prostate can-
cer in African American men but 57% would be more
likely to screen for prostate cancer in a 40 year old male
if he was African American. Figure 3 shows that 55% of
clinicians answered either no or that they are unsure if
prostate cancer screening decreases mortality or morbid-
ity of prostate cancer. And finally, 243 (65.7%) physi-
cians felt that PSA was a useful screening test.
*The above percentage represents out of 304 physicians who routinely sc-
reen men for prostate cancer each year past the age of 50.
Figure 1. Distribution of PSA and DRE screening.
Figure 2. Most common reason cited for performing prostate
cancer screening.
Figure 3. Does screening for prostate cancer decrease mortal-
ity or morbidity of men with prostate cancer?
The NCCN practice guidelines in oncology as well as
the American Urological Association (AUA) and the
ACS all suggest that a baseline PSA level be offered at
age 50 in addition to a baseline digital rectal exam after
a discussion of the risks and benefits of early screening
[2,3,12]. A 1993 study in Missouri by Lawson and col-
leagues found that most primary care physicians felt that
the PSA test was an important screening test for prostate
cancer [13]. The results from Missouri are similar to
West Virginia but the PSA test as a screening tool is still
used with hesitancy by many. The American Academy
of Family Physicians (AAFP), National Institute of
Health (NIH) and the U.S. Preventive Services Task
Force take a position against early prostate cancer
screening [14-16]. The lack of literature to support a
decrease in mortality or morbidity as well as absence of
a treatment option that routinely causes no harm are the
primary concerns voiced by the groups.
The NCCN is currently one of the most trusted reso-
S. Deem et al. / Health 2 (2010) 1179-1183
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
urces available to practitioners for established guidelines
regarding screening, diagnosing and treating various typ-
es of malignancy. They provide evidence based medic-
ine reviews of the current literature and guidelines for
multiple cancers. Twenty-one of the most respected ca-
ncer centers in the world meet frequently to discuss the
literature and establish these guidelines. They are avail-
able at no costs to anyone who can access the Internet
(http:www.nccn.org) and are reported in the urology
literature. The NCCN recommends screening for pros-
tate cancer to include annual DRE and PSA in all men
after the age of 50 after discussing the risks and benefits
of screening with the patient. High risks groups includ-
ing African American males and patients with a family
history of a first degree relative with prostate cancer
should begin screening at age 40. The ACS guidelines
are available online and they recommend offering
screening similar to the NCCN guidelines in a patient
with life expectancy greater than 10 years [2,3].
Performing a DRE prior to checking a PSA level has
been proven to be insignificant. If there is no evidence of
recent urinary retention or catheterization, acute prostati-
tis, prostate needle biopsy, or vigorous therapy that wo-
uld include manipulation of the gland (i.e., colonoscopy
or anal intercourse) then performing a DRE prior to ch-
ecking the PSA level should not affect the results [17].
Patient age and life expectancy, co-morbidities, and his-
tory of prostate enlargement or an elevated PSA should
all be considered when determining whether or not to
obtain urology consultation. When in doubt it is always
best to proceed with specialty inclusion in the decision
planning. PSA velocity is another method of determining
a need for further intervention. Presently a rise in PSA of
> 0.75 ng/ml in one year is an indication for prostate
biopsy in normal circumstances. The NCCN now advo-
cates lowering this threshold to > 0.35 ng/ml in patients
with a PSA level < 4(2).
The only accepted risk factors for prostate cancer are
increased age, African American race, and family histo-
ry, which are not modifiable. The American Cancer Soc-
iety recommends a diet low in saturated fat and red meat.
Selenium and Vitamin E have been reviewed as potential
prevention strategies, however, recent literature showed
no benefit in prostate cancer prevention [18].
5-alpha reductase inhibitors (Finasteride and Dutas-
teride) have been advocated as a potential chemopreven-
tion therapy for prostate cancer. The Prostate Cancer
Prevention Trial (PCPT) randomized men into receiving
either Finasteride or placebo and performed biopsy when
the PSA rose to a level of 4 or greater or an abnormal di-
gital rectal exam was found. Patients were followed for
seven years and a 24.8 percent reduction in the preva-
lence of prostate cancer was found in the Finasteride arm.
However, there was an increase in the number of high
risk cancers found in the Finasteride arm [19]. The Re-
duction by Dutasteride of prostate Cancer Events (RE-
DUCE) trial, showed a 22.8 percent relative reduction in
prostate cancer in the Dutasteride arm indicating effecti-
veness in chemoprevention of prostate cancer. The AUA
and the American Society of Clinical Oncology released
guidelines on chemoprevention of prostate cancer rec-
ommending a discussion with men who met the criteria
on the risks and potential benefits of 5-alpha reductase
inhibitors for prevention of prostate cancer [20].
Aside from these recommendations there are no other
modifiable risks that have been established in the current
literature. This is the basis for why early screening is co-
nsidered by most Urology physicians to be such an obv-
ious recommendation. We can only hope to diagnose the
more aggressive tumors early before they have spread and
allow better control and decreased mortality from this
peculiar disease. Our goal in supporting prostate cancer
screening, as in other types of cancer screening, is to of-
fer everyone the opportunity to have their disease diag-
nosed before it is problematic.
Some limitations of this survey are that it may not be
a representative sample of the primary care physician
population in the U.S. Only 25% of the surveys were re-
turned and some specialty-trained physicians could have
returned their results. The length of time since residency
training could affect the method of prostate cancer scr-
eening to some degree and this was not categorized by
the survey.
Prostate cancer remains an elusive disease with an un-
predictable course causing controversy in screening and
treatment recommendations. Screening for prostate can-
cer will likely be controversial for many years to come.
However, the decline in prostate cancer mortality in the
PSA era can not be ignored. Identification of patients
with prostate cancer that may benefit from early treatm-
ent can only be achieved by following the best evidence
we have to date which would support at least some role
for early prostate cancer screening. Collaboration amon-
gst the various organizations providing guidelines will
be necessary to unify the recommendations and standar-
dize screening to improve the effectiveness of screening
long term.
Primary care physicians currently have a broad range of
commitment to prostate cancer screening which is in ac-
cordance with the lack of quality studies to confirm its
efficacy in decreasing mortality and morbidity in the cu-
rrent literature. The diversity amongst the various guide-
lines and paucity of evidence to support screening cer-
S. Deem et al. / Health 2 (2010) 1179-1183
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
tainly makes the task of providing uniform screening rec-
ommendations difficult. Universal commitment to prost-
ate cancer screening will only be adopted when all guid-
eline panels assimilate and the literature can support th-
em. But with the lack of quality, long-term, randomized
controlled trials to guide the recommendations, we will
likely continue with our current individual best practices
based solely on practice preferences and individual atti-
tudes toward screening.
This study was supported by the CAMC Foundation, Sarah and Pa-
uline Maier Foundation and CAMC Institute, Inc. of Charleston, WV.
We would like to thank Suzanne Kemper, MPH for all of her help with
this project.
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