Jury still out on value of PSA screening

Prostate Cancer Screening Does Not Reduce All-Cause Mortality
Prostate Cancer Screening Does Not Reduce All-Cause Mortality

HealthDay News -- The debate continues about the value of routine prostate cancer screening after extended follow-up data from a major European trial indicate that screening still has benefits.

After 11 years of follow-up, screening men for prostate-specific antigen (PSA) levels reduced the risk for death from prostate cancer by 21%, Fritz Schröder, MD, of Erasmus University Medical Center in Rotterdam, the Netherlands, and colleagues, reported in the New England Journal of Medicine.

The findings from the European Randomized Study of Screening for Prostate Cancer (ERSPC) challenge those of the National Institute of Health-sponsored Prostate, Lung, Colorectal, and Ovarian (PLCO) screening program, which has consistently reported no benefit to using prostate specific antigen (PSA) screening in healthy men.

In October 2011, the United States Preventive Services Task Force (USPSTF) issued preliminary recommendations stating that healthy men do not require routine PSA screening because it often leads to unnecessary testing, interventions and treatment.

The ERSPC trial includes 162,388 men aged 55 to 69 years when they entered the study, who were randomly assigned to PSA screening or no screening. Participants were followed for an average of 10.5 years and a median of 11 years. 

Previously published findings from the initial nine-year ERSPC follow-up period indicate a 20% relative reduction in prostate cancer mortality risk with PSA testing every four years on average.

Data from the additional two years of follow up indicate similar results. After a median of 11 years of follow-up, the researchers found a significant 21% relative reduction in the risk for death from prostate cancer in the screened group. Overall, the rate ratio was 0.79 (95% CI 0.68 to 0.91, P=0.001). After correcting for selection bias and noncompliance, the relative reduction rose to 29%.

The relative reduction was even greater in the final two years of follow-up, at 38%, with a rate ratio of 0.62 (95% CI 0.45 to 0.85, P=0.003). The absolute mortality reduction was 0.10 deaths per 1,000 person-years. However, there was no significant difference in all-cause mortality between the two groups.

"More information on the balance of benefits and adverse effects, as well as the cost-effectiveness, of prostate-cancer screening is needed before general recommendations can be made," Schroder and colleagues concluded.

In an accompanying editorial, Anthony B. Miller, MD, of the Dalla Lana School of Public Health at the University of Toronto, said that the conflicting results from the PLCO and ERSPC trials leave health-care practitioners in an "unsatisfactory situation," in which data is insufficient to recommend abandoning PSA screening.

However, he noted that PLCO trial findings are likely more applicable to the situation in the United States, as the ERSPC study included a mostly PSA-naive population. "Therefore, an intensification of PSA screening would be unwise, and I think it would be advisable to follow the preliminary recommendations of the U.S. Preventive Services Task Force," Miller wrote.

Several ERSPC researchers disclosed financial relationships with pharmaceutical and biotechnology companies.

Schröder FH et al. N Engl J Med. 2012; 366: 981-990.

Miller AB. N Engl J Med. 2012; 366:1047-1048.

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