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PSA-based screening reduces deaths from prostate cancer, finds new review

A re-analysis of available evidence has found that Prostate-Specific Antigen (PSA)-based screening does reduce deaths from prostate cancer.

The findings, published today in the Annals of Internal Medicine, defies existing UK guidance which does not currently recommend universal screening.

The study concluded that ‘two important prostate cancer screening trials provide compatible evidence that screening reduces prostate cancer mortality’.

Current guidelines from the United States Preventive Services Task Force (USPSTF) recommend against PSA-based screening for prostate cancer because the evidence for the test showed very low probability that it would reduce the risk of dying, said the US-based researchers.

But they added that this recommendation relied heavily on results from the ERSPC (European Randomized Study of Screening for Prostate Cancer) and the PLCO (Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial), which offered conflicting results. The ERSPC showed a significant reduction and the PLCO showed no reduction.

The team of investigators from the University of Michigan and the National Cancer Institute sought to formally test whether the effects of screening on prostate cancer mortality differed between the ERSPC and PLCO and to estimate the effects of screening in both trials relative to no screening.

Using a mathematical model to account for differences in implementation compliance, and practice settings, they found no evidence that the effects of screening compared to no screening differed between ERSPC and PLCO and inferred that screening could ‘significantly reduce prostate cancer deaths’.

Although the findings suggest that current guidelines – recommending against routine PSA-based screening – may be revised, the researchers point out that questions remain about how to implement screening so that the benefits outweigh the potential harms of over-diagnosis and over-treatment.

In the UK, the NHS’s resistance to screening for prostate cancer is based on a recommendation made by the UK National Screening Committee.

The committee, which issued its latest recommendations on PSA screening in January last year, says that it does not currently recommend universal screening for prostate cancer.

The committee pointed out that evidence shows a benefit of prostate screening to reduce prostate cancer deaths by 21%. Despite this significant reduction, the harms of treating men who incorrectly test positive still outweigh the benefits, says the Committee.

It stressed that PSA is still a poor test for prostate cancer and a more specific and sensitive test is needed. PSA is also unable to distinguish between slow-growing and fast-growing cancers, said the committee.

Dr Andrew Green, GPC clinical and prescribing policy lead, told Pulse: ‘We already suspect that prostate cancer screening reduces prostate cancer deaths, but there is a world of difference between a difference in rate that is statistically significant for a population and a difference which is clinically significant for an individual. In any case, it should be all-cause mortality and not disease-specific mortality that is analysed.

‘However, the real question is not whether an occasional death can be prevented, but whether the costs to men’s physical and mental health caused by the inevitable over-diagnosis and over-treatment can be justified. The present evidence is that it cannot.’

Readers' comments (8)

  • There is a useful shared decision making aid on this PSA testing

    https://www.evidence.nhs.uk/Search?om=[{%22ety%22:[%22Patient%20Decision%20Aids%22]},{%22srn%22:[%22NHS%20RightCare%22]}]&ps=50&q=psa

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  • Dr Green is right. Unless this has an effect on 'all cause mortality' then unlikely to be of any real value.

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  • Agree with Angus and Dr Green. Hardly surprising that treating more people for prostate cancer reduces recorded deaths from prostate cancer. The question is how the costs (including morbidity and mortality from testing and treatment) balance with this benefit.

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  • Dear All,
    Lets read that again (my bold);
    Using a mathematical MODEL to account for differences in implementation COMPLIANCE, and PRACTICE SETTINGS, they found no evidence that the effects of screening compared to no screening differed between ERSPC and PLCO AND INFERRED that screening COULD ‘significantly reduce prostate cancer deaths’.

    Excellent, so thats all the real world evidence we need.

    Regards
    Paul C

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  • Paul - unless it's rolled out nationally, you would not have the real world data. So of course it will be done on mathematical model with assumptions made.

    Or we can ignore such academia and have a go at rolling out without thinking of it's clinical/cost effectiveness. I hear PSA costs around £20 a pop?

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  • A recent patient of mine read about psa in The Mail. He had no symptoms and benign gland so I advised against, however informed choice led to it being done. The result was borderline which led to referral. A biopsy was done. Sepsis followed which was treated. A month later after many consults I finally diagnosed infective endocarditis and re-admitted him. This led to valve replacement surgery and 6 weeks ITU. What do you think the biopsy result was?

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  • Vinci Ho

    (1) Throughout the years , I realised our local lab had used different assays to measure PSA which also now has different normal ranges with respect to different age groups. But I think the test itself naturally had reached its limits as far as sensitivity and specificity are concerned.
    (2) Even if we had a 'better' screening test for prostate cancer, the national screening will need substantial increase in number of urological experts to cope with new workloads. One can argue that if there is new evidence to support screening , it leads to new incentive for investing with new money . But do you see that new resources coming?
    (3) The conundrum in prostate cancer screening programme is always about picking up those silent cancers which never kill . Unless , there is an non-invasive way to differentiate the high risk from the low risk ones. Cases of harm from over-investigating are always there. Some will argue similarly for national breast cancer screening programme.

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  • Does anyone have any evidence on screening high risk groups specifically? African Caribbean men, for instance. Maybe the outcomes of screening would be better.

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