BACKGROUND: Prostate cancer (PCA) is the most common type of cancer in men. The significant increase in incidence is most likely caused by the overdiagnosis of prostate cancer by widespread prostate-specific antigen (PSA) screening.
OBJECTIVES: This article reviews the three largest randomized trials of PSA-based prostate cancer screening and the benefits and disadvantages of general PSA screening. It gives an overview about the strategies to avoid the harms from overdetection and overtreatment without missing clinically relevant tumors.
METHODS: This review article is based on a literature search in the PubMed database on PSA-based screening, molecular serum markers and risk-adapted PSA screening.
RESULTS: In contrast to the CAP and PLCO trial, the ERSPC study reports a reduced relative and absolute mortality risk. Furthermore, the use of the PSA was associated with significantly lower risk of metastatic disease. In order to avoid unnecessary biopsy and overtreatment including treatment of insignificant prostate cancer, a number of tests have been proposed to improve the specificity of the PSA screening including the PHI, the 4Kscore and the risk-adapted PSA screening. The assessment of a baseline PSA level in the fifth decade allows subsequent risk-adapted PSA screening intervals. This concept is currently evaluated by the largest prospective multicenter trial, the PROBASE-trial.
CONCLUSIONS: Neither a complete rejection of a PSA-based screening nor a general PSA testing is a final solution to this dilemma. A risk-adapted PSA screening according to a baseline PSA as well as serum markers may reduce unnecessary diagnostic and therapeutic interventions and its attendant morbidities without a decrease in sensitivity.
Context: The relationship between early detection of prostate cancer (PCa) and disease-specific mortality is still the subject of much debate. Objective: This review describes developments in PCa mortality rates and disease-stage shift on a population level. The main findings from the randomised screening trials are also discussed. Finally, we consider the expected consequences for the individual man interested in screening. Evidence acquisition: The PubMed database was searched for trials of screening for PCa from inception through October 11, 2014. Supplementary information was collected by cross-referencing the reference lists. Evidence synthesis: Since the introduction of prostate-specific antigen testing, PCa incidence has risen, and a stage shift towards more favourable disease at diagnosis has been observed. PCa mortality rates are gradually decreasing. Although screening trials show conflicting results, the largest randomised trial of screening for PCa shows a 21% decrease in PCa-specific mortality. After correction for noncompliance and contamination, a risk reduction in PCa-specific mortality of up to 49% has been reported. The main side effect of screening is that some studies have estimated that approximately 50% of detected cases may represent overdiagnosis, which may be reduced by stopping screening in older men and using an individual risk-based approach. Conclusions: To maximise the benefits while minimising the risk of overdiagnosis, future screening should follow an individual risk-based approach. Patient summary: On a population level, the introduction of screening for prostate cancer (PCa) is associated with more men diagnosed but with more favourable disease. The largest screening study confirmed the reduction in death due to PCa. Individual risk estimation is important to best balance the benefits and potential harms of early detection. Screening is associated with higher prostate cancer incidence and lower mortality rates on a population level. The main randomised trial also found that organised prostate-specific antigen screening reduces advanced disease and death. Risk-based screening in specific populations may optimise individual benefits.
Prostate cancer (PCA) is the most common type of cancer in men. The significant increase in incidence is most likely caused by the overdiagnosis of prostate cancer by widespread prostate-specific antigen (PSA) screening.
OBJECTIVES:
This article reviews the three largest randomized trials of PSA-based prostate cancer screening and the benefits and disadvantages of general PSA screening. It gives an overview about the strategies to avoid the harms from overdetection and overtreatment without missing clinically relevant tumors.
METHODS:
This review article is based on a literature search in the PubMed database on PSA-based screening, molecular serum markers and risk-adapted PSA screening.
RESULTS:
In contrast to the CAP and PLCO trial, the ERSPC study reports a reduced relative and absolute mortality risk. Furthermore, the use of the PSA was associated with significantly lower risk of metastatic disease. In order to avoid unnecessary biopsy and overtreatment including treatment of insignificant prostate cancer, a number of tests have been proposed to improve the specificity of the PSA screening including the PHI, the 4Kscore and the risk-adapted PSA screening. The assessment of a baseline PSA level in the fifth decade allows subsequent risk-adapted PSA screening intervals. This concept is currently evaluated by the largest prospective multicenter trial, the PROBASE-trial.
CONCLUSIONS:
Neither a complete rejection of a PSA-based screening nor a general PSA testing is a final solution to this dilemma. A risk-adapted PSA screening according to a baseline PSA as well as serum markers may reduce unnecessary diagnostic and therapeutic interventions and its attendant morbidities without a decrease in sensitivity.
