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Purpose: To evaluate the potential benefits, harms, and economic consequences of digital rectal examination and measurement of prostate-specific antigen (PSA) for the early detection of prostate cancer.Data Sources: Relevant studies were identified from a MEDLINE search (1966 to 1995), reviews, bibliographies of retrieved articles, author files, and abstracts.Study Selection: Probabilities for individual clinical outcomes were derived from various sources, including the largest screening study of community volunteers to data, analyses of Medicare claims, and recently published meta-analyses of the outcomes of alternative treatment strategies. Cost estimates were based on the 1992 Medicare fee schedule.Data Extraction: A cost-effectiveness model for one-time digital rectal examination and PSA measurement was constructed to examine the possible outcomes.Results: If a favorable set of assumptions is used, one-time digital rectal examination and PSA measurement may increase average life expectancy by approximately 2 weeks at a reasonable marginal cost for men who are between 50 and 69 years of age. Considerable iatrogenic illness would occur. If less favorable assumptions are used, the estimated net benefit would decrease and cost-effectiveness ratios would dramatically increase. Even if favorable assumptions are used, the model suggests that screening adds only a few days to the average life expectancy of men who are older than 69 years of age. If the assumptions are less favorable, older men are harmed.Conclusions: The model suggests that screening may be reasonable in younger men if optimistic assumptions consistent with existing observational data are made. The lack of direct evidence showing a net benefit of screening for prostate cancer seems to mandate more clinician-patient discussion for this procedure than for many other routine tests. [ABSTRACT FROM AUTHOR]

Purpose: To estimate the prevalence of clinically important prostate cancer and to evaluate the effectiveness of digital rectal examination and measurement of prostate-specific antigen (PSA) in early detection of prostate cancer.Data Sources: Relevant studies were identified from a structured MEDLINE search (1966 to 1995), reviews, bibliographies of retrieved articles, author files, and abstracts.Study Selection: Articles selected for analysis of test effectiveness were prospective cohort studies of early detection that did not have obvious selection bias.Data Extraction: Likelihood ratios for digital rectal examination and PSA measurement were estimated from studies that specified the age distribution of participants.Data Synthesis: In patients who have abnormalities on digital rectal examination, the risk for a large intracapsular tumor is increased twofold but the risk for extracapsular disease is increased threefold to ninefold. An elevation in PSA level greater than 4 ng/mL increases the odds of intracapsular tumors by as much as threefold and the odds of extracapsular tumors by threefold to fivefold. For studies in which biopsies were done if results of either test were abnormal, 18% to 26% of screened patients had suspicious results, cancer detection rates were approximately 4%, and the positive predictive value of the tests combined was 15% to 21%. Men who have lower urinary tract symptoms that are consistent with benign prostatic hyperplasia are not more likely to harbor prostate cancer; the specificity of PSA measurement is considerably lower among these men.Conclusions: Larger-volume tumors of the prostate are common among older men. Available tests for the early detection of cancer have limited specificity, which necessitates a relatively high biopsy rate. The positive predictive value of combined digital rectal examination and PSA measurement has been defined, but the negative predictive value is less clear. Measurement of PSA is the most sensitive noninvasive test for prostate cancer. However, digital rectal examination detects cancer that would otherwise be missed by PSA measurement. [ABSTRACT FROM AUTHOR]