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CME

Prostate Cancer Screening

General Information

General InformationGeneral Information

Description

  • prostate cancer screening aims at maximizing detection of prostate cancer that can be effectively treated and that, if left undetected, can represent a risk to the patient3
  • maximizing detection of early prostate cancer increases detection of both indolent (slower growing) and aggressive (faster growing) disease, and may help minimize overtreatment of indolent cancers with accurate characterization of tumors3
  • prostate cancer screening is typically based on testing for serum prostate-specific antigen (PSA) levels, and may also include digital rectal examination (DRE)4
  • goal of prostate cancer screening is to maximize benefits and minimize harms of PSA testing4
  • PSA is a kallikrein-related serine protease, a glycoprotein that liquefies seminal coagulum3,4
  • PSA is not a prostate cancer-specific marker since it is secreted by both malignant and nonmalignant prostatic epithelial cells3,4
    • serum PSA levels may increase due to several causes other than prostate cancer, including prostatitis, benign prostatic hyperplasia, recent instrumentation, ejaculation, or trauma
    • most men with elevated PSA levels do not have prostate cancer - only about 25% of men with PSA levels 4-10 ng/mL are reported to have a subsequent positive biopsy
  • despite its limitations, PSA levels reportedly strongly correlate with risk and outcome of prostate cancer4
  • decision to offer testing for prostate cancer should be based on individual’s estimated life expectancy as well as probability that a clinically significant cancer may be present4

Incidence, prevalence, and mortality for prostate cancer

  • prostate cancer is one of the most commonly diagnosed cancers worldwide (7.1% of estimated global new cancer cases in 2018), and the second leading cause of cancer death in United States
  • Study Summary
    estimated global prostate cancer incidence 1,276,106 cases in 2018
    Details
    studySummary
    • based on population-based cancer registries, vital registration data, and mortality data from 185 countries or territories with total population > 150,000 during 2018
    • estimated global new prostate cancer cases 1,276,106 in 2018 (7.1% of all new cancer cases)
    • cumulative global lifetime risk (ages 0-74 years) 3.73%
    • age-standardized rates (ASRs) for incidence of prostate cancer
      • overall ASR 29.3 per 100,000 men
      • in more developed regions, ASR 37.5 per 100,000 men
      • in less developed regions, ASR 11.4 per 100,000 men
      Table 1. Estimated Global Prostate Incidence by Global Region, 2018
      RegionASRs per 100,000
      Americas
      North America73.7
      Central America42.2
      Caribbean64.2
      South America60.4
      Africa
      Northern Africa13.2
      Western Africa31.9
      Middle Africa35.9
      Eastern Africa23.9
      Southern Africa64.1
      Europe
      Western Europe75.8
      Northern Europe85.7
      Southern Europe60.7
      Eastern Europe42.2
      Asia
      Western Asia26.9
      South Central Asia5
      Eastern Asia13.9
      South-Eastern Asia12.7
      Oceana
      Australia/New Zealand86.4
      Melanesia34.1
      Micronesia/Polynesia55.6
      Abbreviations: ASR, age-standardized rates.
    • CA: a cancer journal for clinicians20181101CA Cancer J Clin686394394Reference - GLOBOCAN 2018 (CA Cancer J Clin 2018 Nov;68(6):394full-text)
  • prostate cancer accounts for 1 in 5 new cancer diagnoses in men in United States
    • estimated 174,650 new cases of prostate cancer diagnosed in 2019
    • lifetime risk of developing prostate cancer 11.2% in United States
      • 0.2% risk from birth to age 49 years
      • 1.7% risk from ages 50-59 years
      • 4.6% risk from ages 60-69 years
      • 7.9% risk from ages ≥ 70 years
    • incidence rates by race and ethnicity in United States from 2011 to 2016
      • 179.2 per 100,000 persons for non-Hispanic black men
      • 101.7 per 100,00 for non-Hispanic white men
      • 91.6 per 100,000 for Hispanic men
      • 73.1 per 100,000 for American Indian/Alaska Native men
      • 56 per 100,000 for Asian/Pacific Islander men
    • stage distribution of prostate cancer by race in United States from 2008 to 2014
      Table 2. Incidence of Prostate Cancer by Stage and Race
       Localized Disease*Regional Disease**Distant Disease***
      All men> 99%> 99%30%
      White men> 99%> 99%29%
      Black men>99%> 99%30%
      * Localized disease is stage I and II if negative lymph node(s).

      ** Regional disease is stage II and III if positive lymph node(s).

      *** Distant disease is metastatic, stage IV.

    • Reference - CA Cancer J Clin 2019 Jan;69(1):7full-text
  • trends in prostate cancer incidence in men ≥ 50 years old after updated recommendations from US Preventative Services Task Force (USPSTF) in cohort study of 446,009 men
  • worldwide prevalence of incidental prostate cancer by age in systematic review
    • systematic review of 29 case series evaluating worldwide prevalence of incidental prostate cancer at autopsy in 8,776 men who died of non-prostate cancer-related causes
    • mean prevalence of incidental prostate cancer
      • 5% at age < 30 years
      • 15% at age 40-50 years
      • 59% at age > 79 years
    • each 10-year increase in age associated with increased risk of incidental prostate cancer (adjusted odds ratio 1.71, 95% CI 1.62-1.81)
    • Reference - 25821151Int J Cancer 2015 Oct 1;137(7):1749full-text
  • Study Summary
    estimated global prostate cancer mortality 358,989 in 2018
    Details
    studySummary
    • based on population-based cancer registries, vital registration data, and mortality data from 185 countries or territories with total population > 150,000 during 2018
    • mortality
      • estimated global prostate cancer mortality 358,989
      • age-standardized rate (ASR) 7.6 per 100,000 men
      • cumulative global lifetime risk of death (ages 0-74 years) 0.6%
      Table 3. Estimated Global Prostate Cancer Mortality by Global Region, 2018
      RegionAge-Standardized Rates per 100,000
      Americas
      North America7.7
      Central America10.7
      Caribbean25.4
      South America14
      Africa
      Northern Africa5.8
      Western Africa18.6
      Middle Africa22.7
      Eastern Africa14.8
      Southern Africa26.8
      Europe
      Western Europe10.1
      Northern Europe13.5
      Southern Europe7.9
      Eastern Europe13.5
      Asia
      Western Asia8
      South Central Asia3.3
      Eastern Asia4.7
      South-Eastern Asia5.4
      Oceana
      Australia/New Zealand10.2
      Melanesia14.5
      Micronesia/Polynesia18.2
    • CA: a cancer journal for clinicians20181101CA Cancer J Clin686394394 Reference - GLOBOCAN 2018 (CA Cancer J Clin 2018 Nov;68(6):394full-text)
  • prostate cancer second leading cause of death from cancer in men in United States
    • estimated 31,620 deaths from prostate cancer in United States in 2019
      • mortality higher for non-Hispanic black men in United States from 2011 to 2016
        • 39.8 per 100,000 persons for non-Hispanic black men
        • 19.1 per 100,000 for American Indian/Alaska Native men
        • 18.1 per 100,00 for non-Hispanic white men
        • 15.9 per 100,000 for Hispanic men
        • 8.6 per 100,000 for Asian/Pacific Islander men
      • overall death rate decreased 51% for years 1993-2016
    • Reference -CA Cancer J Clin 2019 Jan;69(1):7full-text
      Prostate cancer relative survival trends
      Image 1 of 1

      Prostate cancer relative survival trends

      Relative survival rates for patients with prostate cancer, stratified by stage and race.

Risk factors for prostate cancer

  • major risk factors for prostate cancer include4
    • increased age
    • African-American ethnicity
    • family history (particularly first-degree relatives)
      • 2-fold increased risk, 1 first-degree relative
      • 4-fold increased risk, ≥ 2 first-degree relatives
    • BRCA1 and BRCA2 mutations; men with BRCA2 mutation reported to be diagnosed at younger age, with higher-risk disease, and lymph node and/or distant metastases
  • factors reportedly associated with decreased risk include consumption of isoflavonoid genistein (found in legumes), cruciferous vegetables, lycopene, and statin drugs4
  • family history
    • Study Summary
      presence of first-degree relative with prostate cancer may be associated with increased risk
      Details
      studySummary
      • based on systematic review of observational studies Systematic Review
      • systematic review of 33 observational studies (5 prospective cohort studies, 20 retrospective case-control studies, and 3 registry linkage studies) evaluating family history in 200,215 patients with prostate cancer
      • compared to patients without first-degree family history of prostate cancer, presence of family history associated with increased risk of prostate cancer (relative risk 2.53, 95% CI 2.24-2.85)
      • PubMed12673715Cancer20030415Cancer97818941894 Reference - 12673715Cancer 2003 Apr 15;97(8):1894full-text
    • Study Summary
      first-degree family history of prostate cancer associated with increased risk for overall prostate cancer, but not aggressive prostate cancer
      Details
      studySummary
      • based on cohort analysis of data from randomized trial Randomized Trial
      • 4,932 Swiss men (mean age 61 years) from ERSPC trial were assessed for family history of prostate cancer
      • 6.8% had positive first-degree family history of prostate cancer
      • comparing men with positive family history vs. men without family history
        • overall prostate cancer incidence 18% vs. 12% (p < 0.001)
        • aggressive prostate cancer incidence 5.1% vs. 4% (not significant)
      • PubMed26332304BJU international20160401BJU Int1174576576 Reference - mnh26332304paph113705957t pa9h113705957t pbyh113705957t pcxh113705957t pmdc26332304pBJU Int 2016 Apr;117(4):576
    • Study Summary
      family history of prostate cancer associated with increased risk for prostate cancer
      Details
      studySummary
      • based on prospective cohort study Cohort Study
      • 7,904,092 persons aged 0-76 years in Sweden and their biological parents were analyzed
      • 36,878 persons had prostate cancer
      • compared to having no affected parent, having parent with prostate cancer associated with increased risk of prostate cancer (adjusted hazard ratio 2.3, 95% CI 2.2-2.4)
      • having parent diagnosed with cancer at early age associated with highest familial risk
      • PubMed23257063BMJ (Clinical research ed.)20121220BMJ345e8076e8076 Reference - 23257063BMJ 2012 Dec 20;345:e8076full-text, commentary can be found in 23734355J R Coll Physicians Edinb 2013;43(2):134
    • no significant association between family history of prostate cancer and risk of detecting prostate cancer in cohort study of 20,311 men aged 55-67 years (mdc12039927pJ Clin Oncol 2002 Jun 1;20(11):2658full-text)
  • BRCA1 or BRCA2 mutation
  • higher body mass index
    • Study Summary
      higher body mass index associated with increased risk of advanced prostate cancer
      Details
      studySummary
      • based on systematic review
        • 13 studies with 1,080,790 men had 7,067 cases of advanced prostate cancer
        • 12 studies with 1,033,009 men had 19,130 cases of localized prostate cancer
        Systematic Review
      • each increase in body mass index (BMI) of 5 kg/m2 associated with
        • increased risk of advanced prostate cancer (relative risk 1.09, 95% CI 1.02-1.16)
        • decreased risk of localized prostate cancer (relative risk 0.94, 95% CI 0.91-0.97)
      • PubMed22228452Annals of oncology : official journal of the European Society for Medical Oncology20120701Ann Oncol23716651665 Reference - 22228452Ann Oncol 2012 Jul;23(7):1665full-text
    • Study Summary
      higher body mass index associated with increased risk of prostate cancer mortality
      Details
      studySummary
      • based on systematic review Systematic Review
      • systematic review of 6 population-based cohort studies evaluating mid/late life BMI and prostate cancer-specific mortality with 1,263,483 initially cancer-free men
      • prostate cancer mortality 0.53%
      • each 5 kg/m2 increase in BMI associated with increased risk for prostate cancer mortality (relative risk 1.15, 95% CI 1.06-1.25)
      • PubMed21233290Cancer prevention research (Philadelphia, Pa.)20110401Cancer Prev Res (Phila)44486486 Reference - 21233290Cancer Prev Res (Phila) 2011 Apr;4(4):486full-text
  • inconsistent evidence for risk of prostate cancer after vasectomy
  • inconsistent evidence for risk of prostate cancer and levels of endogenous or exogenous testosterone
  • exposure to infection or toxins
    • Study Summary
      agent orange exposure associated with increased risk of high-grade prostate cancer
      Details
      studySummary
      • based on prospective cohort study Cohort Study
      • 2,720 veterans having prostate biopsy were analyzed
      • 32.9% had prostate cancer and 16.9% had high-grade (Gleason score ≥ 7) prostate cancer
      • compared to no agent orange exposure, agent orange exposure associated with increased risk of
        • high-grade prostate cancer (adjusted odds ratio 1.75, 95% CI 1.12-2.74)
        • prostate cancer with Gleason score ≥ 8 (adjusted odds ratio 2.1, 95% CI 1.22-3.62)
      • no significant association between agent orange exposure and low-grade prostate cancer
      • PubMed23670242Cancer20130701Cancer1191323992399 Reference - 23670242Cancer 2013 Jul 1;119(13):2399full-text
    • Study Summary
      rescue and/or recovery work at World Trade Center site associated with increased risk of prostate cancer, thyroid cancer, and multiple myeloma
      Details
      studySummary
      • based on prospective cohort studyCohort Study
      • 55,778 residents of New York State who enrolled in World Trade Center Health Registry during 2003-2004 were followed through 2008
        • 39% were rescue and/or recovery workers at or near site of World Trade Center attacks from September 11, 2001 to June 30, 2002
        • 61% were not involved in rescue or recovery efforts but lived, worked, or attended school near World Trade Center site
      • 1,187 incident cancers were diagnosed during 253,269 person-years of follow-up (439 incident cancers in rescue and/or recovery workers)
      • compared to general population during 2007-2008, rescue and/or recovery work associated with increased risk of incident
        • prostate cancer (adjusted standardized incident ratio [SIR] 1.43, 95% CI 1.11-1.82)
        • multiple myeloma (adjusted SIR 2.85, 95% CI 1.15-5.88)
        • thyroid cancer (adjusted SIR 2.02, 95% CI 1.07-3.45)
      • no significant difference in cancer risk for persons not involved in rescue or recovery but exposed to World Trade Center site compared to general population during 2007-2008
      • intensity of World Trade Center exposure not associated with lung cancer, prostate cancer, thyroid cancer, non-Hodgkin lymphoma, or hematological cancer in either group
      • PubMed23288447JAMA20121219JAMA3082324792479Reference - 23288447JAMA 2012 Dec 19;308(23):2479, commentary can be found in 23549571JAMA 2013 Apr 3;309(13):1344
  • Study Summary
    fathering children through in vitro fertilization (IVF) and intra-cytoplasmic sperm injection (ICSI) each associated with increased risk of prostate cancer before age 55 years
    Details
    studySummary
    • based on population-based cohort studyCohort Study
    • 1,181,490 fathers who had live born children in Sweden during 1994-2014 were assessed
    • 1.7% fathered children by IVF, 1.5% fathered children by ICSI, and 97% fathered children by natural conception
    • total follow-up 14,389,198 person-years
    • diagnosis of prostate cancer in
      • 0.37% with IVF (adjusted hazard ratio [HR] 1.33, 95% CI 1.06-1.66 vs. natural conception)
      • 0.42% with ICSI (adjusted HR 1.64, 95% CI 1.25-2.15 vs. natural conception)
      • 0.28% with natural conception
    • compared to natural conception, increased risk of prostate cancer before age 55 years associated with
      • IVF (adjusted HR 1.51, 95% CI 1.09-2.08)
      • ICSI (adjusted HR 1.86, 95% CI 1.25-2.77)
    • PubMed31554611BMJ (Clinical research ed.)BMJ20190925366l5214l5214Reference - BMJ 2019 Sep 25;366:l5214full-text, editorial can be found in BMJ 2019 Sep 25;366:l5525
  • Study Summary
    elevated 25-hydroxyvitamin D levels may be associated with increased risk of prostate cancer
    Details
    studySummary
    • based on systematic review of observational studies Systematic Review
    • systematic review of 21 observational studies (3 cohort studies and 18 case-control studies) evaluating association between circulating 25-hydroxyvitamin D levels and risk of prostate cancer in 52,811 men
    • 46% had prostate cancer
    • cutoffs for stratification of circulating 25-hydroxyvitamin D levels varied across studies
    • elevated circulating 25-hydroxyvitamin D levels associated with increased risk of prostate cancer (odds ratio 1.17, 95% CI 1.05-1.3) in analysis of all studies
    • PubMed24838848Journal of cancer research and clinical oncology20140901J Cancer Res Clin Oncol140914651465 Reference - mnh24838848pcxh97444876pmdc24838848pJ Cancer Res Clin Oncol 2014 Sep;140(9):1465

References

General references used

  1. Hayes JH, Barry MJ. Screening for prostate cancer with the prostate-specific antigen test: a review of current evidence. JAMA. 2014 Mar 19;311(11):1143-9
  2. Knight SJ. Decision making and prostate cancer screening. Urol Clin North Am. 2014 May;41(2):257-66
  3. Carroll PR, Parsons JK, Andriole G, et al. Prostate Cancer Early Detection. Version 1.2019. In: National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology (NCCN Guidelines). NCCN 2019 Jan from NCCN website (free registration required)
  4. Eastham J. Prostate cancer screening. Investig Clin Urol. 2017 Jul;58(4):217-219full-text

Recommendation grading systems used

  • American Urological Association (AUA) recommendation grading system
    • grades of evidence
      • Grade A Evidence - high-quality evidence
      • Grade B Evidence - moderate-quality evidence
      • Grade C Evidence - low-quality evidence
    • strength of statement
      • Standard - action should (benefits outweigh risks/burdens) or should not (risks/burdens outweigh benefits) be taken based on Grade A or Grade B Evidence
      • Recommendation - action should (benefits outweigh risks/burdens) or should not (risks/burdens outweigh benefits) be taken based on Grade C Evidence
      • Option - decision regarding an action is left to clinician and patient because balance between benefits and risks/burdens appears equal or appears uncertain based on Grade A, B, or C Evidence
      • Clinical Principle - statement about a component of clinical care that is widely agreed upon by urologists or other clinicians for which there may or may not be evidence in the medical literature
      • Expert Opinion - a statement, achieved by consensus of the Panel, based on members' clinical training, experience, knowledge, and judgment for which there is no evidence
    • Reference - AUA guideline on early detection of prostate cancer (23659877J Urol 2013 Aug;190(2):419full-text),reaffirmed 2018
  • European Association of Urology (EAU) uses Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system
    • strength of recommendation
      • Strong or Weak based on:
        • overall quality of existing evidence
        • magnitude of effect (individual or combined effects)
        • certainty of results (including precision, consistency, heterogeneity, and other statistical or study-related factors)
        • balance between desirable and undesirable outcomes
        • patient values and preferences
        • certainty of patient values and preferences
    • levels of evidence
      • Level 1a - meta-analysis of randomized trials
      • Level 1b - ≥ 1 randomized trial
      • Level 2a - ≥ 1 well-designed controlled study without randomization
      • Level 2b - ≥ 1 other type of well-designed quasi-experimental study
      • Level 3 - well-designed nonexperimental studies; such as comparative studies, correlation studies, and case reports
      • Level 4 - expert committee reports or opinions or clinical experience of respected authorities
    • Reference - EAU guideline on prostate cancer (EAU 2019)
  • American Society of Clinical Oncology (ASCO) grading system
    • recommendation
      • Evidence based - sufficient evidence from published studies to inform recommendation to guide clinical practice
      • Formal consensus
        • available evidence deemed insufficient to inform recommendation to guide clinical practice
        • expert panel used formal consensus process to reach recommendation, which is considered best current guidance for practice
        • panel may choose to provide strength of recommendation (that is, strong, moderate, or weak)
      • Informal consensus
        • available evidence deemed insufficient to inform recommendation to guide clinical practice
        • recommendation considered best current guidance for practice based on informal consensus of expert panel
        • panel may choose to provide strength of recommendation (that is, strong, moderate, or weak)
      • No recommendation
        • insufficient evidence, confidence, or agreement to provide recommendation to guide clinical practice at this time
        • panel deemed evidence insufficient and concluded formal consensus process unlikely to achieve level of agreement needed for recommendation
    • strength of recommendation
      • Strong - high confidence that recommendation reflects best practice based on
        • strong evidence for true net effect (for example, benefits exceed harms)
        • consistent results, with no or minor exceptions
        • no or minor concerns about study quality
        • extent of panelist agreement
        • other compelling considerations
      • Moderate - moderate confidence that recommendation reflects best practice based on
        • good evidence for true net effect (for example, benefits exceed harms)
        • consistent results, with minor and/or few exceptions
        • minor and/or few concerns about study quality
        • extent of panelist agreement
        • other compelling considerations
      • Weak - some confidence that recommendation offers best current guidance for practice based on
        • limited evidence for true net effect (for example, benefits exceed harms)
        • consistent results, with important exceptions
        • concerns about study quality
        • extent of panelist agreement
        • other considerations
    • strength of evidence
      • Strong
        • high confidence that available evidence reflects true magnitude and direction of net effect (that is, balance of benefits vs. harms)
        • further research very unlikely to change either magnitude or direction of this net effect
      • Moderate
        • moderate confidence that available evidence reflects true magnitude and direction of net effect
        • further research unlikely to alter direction of net effect, although may alter magnitude of net effect
      • Weak
        • low confidence that available evidence reflects true magnitude and direction of net effect
        • further research may change either magnitude and/or direction of net effect
      • Insufficient
        • evidence insufficient to determine true magnitude and direction of net effect
        • further research may better inform topic
        • use of consensus opinion of experts reasonable to inform outcomes related to topic
    • Reference - ASCO clinical opinion on screening for prostate cancer with prostate-specific antigen testing (cxh79352720pmdc22802323pJ Clin Oncol 2012 Aug 20;30(24):3020full-text)
  • National Comprehensive Cancer Network (NCCN) categories of evidence and consensus
    • Category 1 - based on high-level evidence, there is uniform NCCN consensus that intervention is appropriate
    • Category 2A - based on lower-level evidence, there is uniform NCCN consensus that intervention is appropriate
    • Category 2B - based on lower-level evidence, there is NCCN consensus that intervention is appropriate
    • Category 3 - based on any level of evidence, there is major NCCN disagreement that intervention is appropriate
    • Reference - NCCN Categories of Evidence and Consensus
  • United States Preventive Services Task Force (USPSTF) grades of recommendation (June 2007 to June 2012)
    • Grade A - USPSTF recommends the service with high certainty of substantial net benefit
    • Grade B - USPSTF recommends the service with high certainty of moderate net benefit or moderate certainty of moderate-to-substantial net benefit
    • Grade C - clinicians may provide the service to select patients depending on individual circumstances; however, only small benefit is likely for most individuals without signs or symptoms
    • Grade D - USPSTF recommends against providing the service with moderate-to-high certainty of no net benefit or harms outweighing benefits
    • Grade I - insufficient evidence to assess balance of benefits and harms
    • Reference - USPSTF Grade Definitions
  • Canadian Task Force on Preventive Health Care (CTFPHC) uses Grading of Recommendations Assessment, Development, and Evaluation (GRADE)
    • strength of recommendations
      • Strong
        • desirable effects of intervention outweigh its undesirable effects OR undesirable effects outweigh its desirable effects
        • implies most individuals best served by recommended course of action
      • Weak
        • desirable effects of intervention probably outweigh undesirable effects OR undesirable effects probably outweigh its desirable effects but there is appreciable uncertainty
        • implies most individuals would want recommended course of action but many would not
    • quality of evidence
      • High - further research is unlikely to change the confidence in the estimate of effect
      • Moderate - further research is likely to have an important impact on the confidence in the estimate of effect and may change the estimate
      • Low - further research is very likely to have an important impact on the confidence in the estimate of effect and is likely to change the estimate
      • Very low - any estimate of effect is very uncertain
    • Reference - 25349003CMAJ 2014 Nov 4;186(16):1225PDF

Synthesized Recommendation Grading System for DynaMed Content

  • The DynaMed Team systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based Methodology).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed content, we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
    • Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
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      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
      • All steps in this process (including evidence summaries which were shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
    • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
    • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
    • If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the dissenting commentary is included in the topic details.
    • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

DynaMed Editorial Process

  • DynaMed topics are created and maintained by the DynaMed Editorial Team and Process.
  • All editorial team members and reviewers have declared that they have no financial or other competing interests related to this topic, unless otherwise indicated.
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Special acknowledgements

  • The American College of Physicians (Marjorie Lazoff, MD, FACP; ACP Deputy Editor, Clinical Decision Resource) provided review in a collaborative effort to ensure DynaMed provides the most valid and clinically relevant information in internal medicine.
  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
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National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T113802, Prostate Cancer Screening; [updated 2018 Nov 30, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T113802. Registration and login required.

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