Prostate cancer screening

There is a lack of data from randomised control trials which show the benefit to harm ratio of using the PSA test for prostate cancer screening. But evidence from Europe has shown that the PSA test can be used to save lives but it is unknown how many cases would be diagnosed and subsequently overtreated (1).

• interim results from a large European randomised controlled trial (2) and a large US study show that screening with prostate-specific antigen (PSA) testing (combined with digital rectal examination [DRE] in the US study) (3) detects many more cancers than usual care
  • in the US, before the use of PSA test (pre-PSA era) the lifetime risk of prostate cancer diagnosis was around 8% while it has risen to 19% in the current PSA era (1)
• however, a review notes caution and states
  • "..the value of prostate cancer screening is still unclear.... whether or not this (results of the studies mentioned) translates into a survival benefit from prostate cancer remains uncertain.."(4)
    • interim results from the European study (n=162,243) suggest that, over nine years, 1,410 men would need to be screened with PSA testing (and 48 additional men with cancer would need to be treated) to prevent one death from prostate cancer
• a US cross-sectional study (5) noted:
  • Question Was the 2012 US Preventive Services Task Force (USPSTF) Grade D recommendation against prostate-specific antigen (PSA) screening for all men associated with prostate cancer–specific mortality (PCSM)?
  • Findings This cross-sectional study found statistically significant changes in PCSM rates that coincided with the change in the screening guideline; PCSM rates were decreasing prior to the recommendation and remained steady after the recommendation.
  • Meaning This study suggests that the change in the USPSTF PSA screening guideline to a Grade D recommendation against PSA screening for all men may have been associated with the stagnancy of PCSM rates
• a study investigated whether a single invitation for a prostate-specific antigen (PSA) screening test reduce prostate cancer mortality at 15-year follow-up compared with no invitation for testing (6):
  • secondary analysis of a randomized clinical trial of 415 357 men aged 50 to 69 years randomized to a single invitation for PSA screening (n = 195 912) or a control group without PSA screening (n = 219 445) and followed up for a median of 15 years, risk of death from prostate cancer was lower in the group invited to screening (0.69% vs 0.78%; mean difference, 0.09%) compared with the control group
  • study authors stated that "..showed that compared with no invitation for routine PSA testing, a single invitation for a PSA screening test reduced prostate cancer mortality at a median follow-up of 15 years, but the absolute mortality benefit was small.."

The national screening committee recommends that screening programmes to detect prostate cancer should not be introduced at present in the UK. The Prostate Cancer Risk Management Programme was introduced in place of this with the aim of providing good quality information about the advantages and disadvantages of the PSA test. This in turn would help men who consider undergoing this test make an informed choice (1).

Reference:

1. Prostate Cancer Risk Management Programme Information for primary care; PSA testing in asymptomatic men. Evidence document. NHS Cancer Screening Programmes, 2010
2. MeReC Extra No 40 July 2009
3. Schröder FH, Hugosson J, Roobol MJ, et al, for the ERSPC investigators. Screening and prostate-cancer mortality in a randomized European study. N Engl J Med 2009;360:132-8
4. Andriole GL, Crawford ED, Grubb RL, et al, for the PLCO Project Team. Mortality results from a randomized prostate-cancer screening trial. N Engl J Med 2009;360:1310-9
5. Burgess L, Aldrighetti CM, Ghosh A, et al. Association of the USPSTF Grade D Recommendation Against Prostate-Specific Antigen Screening With Prostate Cancer-Specific Mortality. JAMA Netw Open. 2022;5(5):e2211869. doi:10.1001/jamanetworkopen.2022.11869
6. Martin RM, Turner EL, Young GJ, et al. Prostate-Specific Antigen Screening and 15-Year Prostate Cancer Mortality: A Secondary Analysis of the CAP Randomized Clinical Trial. JAMA. Published online April 06, 2024. doi:10.1001/jama.2024.4011