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Low-intensity PSA-based screening does not reduce mortality, but leads to overdiagnosis and potential harm
Clinical Question
Does prostate cancer screening with an invitation for prostate-specific antigen testing reduce prostate cancer–specific mortality?
Bottom line
Low-intensity screening for prostate cancer consisting of a single invitation to undergo prostate-specific antigen (PSA) testing in men aged 50 to 69 years has no effect on prostate cancer–specific mortality or all-cause mortality after a median follow-up of 10 years. However, testing did lead to a significant increase in the detection of early-state, low-grade prostate cancer, especially among younger men. Presumably many of these men experienced increased anxiety and may have undergone unnecessary interventions resulting in increased morbidity, including incontinence and impotence. 1b-
Reference
Study design: Randomized controlled trial (nonblinded)
Funding: Government
Setting: Outpatient (primary care)
Synopsis
These investigators randomized (allocation assignment not concealed) 911 primary care practices located near 8 hospital centers in the United Kingdom to offer 50- to 69-year-old men a single invitation to undergo PSA testing, followed by prostate biopsy in men with PSA levels of 3 ng/mL or greater. Control practices provided information about PSA testing only to men requesting it. Individuals who assessed outcomes remained masked to intervention group assignment. Using intention-to-treat analysis, 40% of men who attended the intervention practices underwent PSA testing. Approximately 10% to 15% of men from the control practices also underwent PSA testing. After a median follow-up of 10 years, there was no significant group difference in prostate cancer–related mortality or all-cause mortality. However, the number of men given a diagnosis of prostate cancer was significantly higher in the intervention group than in the control group (4.3% vs 3.6%). Men in the intervention group with prostate cancer were significantly younger and their tumors were significantly more likely to be low-grade (Gleason grade of 6 or less).
Reviewer
David C. Slawson, MD
Professor and Vice Chair of Family Medicine for Education and Scholarship
Atrium Health
Professor of Family Medicine, UNC Chapel Hill
Charlotte, NC
Comments
Men still die of prostate cancer. It would be nice to work out at what age PSA testing is reasonable, if any.
There really are no good guidelines regarding prostate screening. We really need to find a better way. DRE isn’t useful and neither is PSA
I hope they follow mortality outcomes for another decade.
Interesting study design of whether to offer "low-intensity" screening to patients or not. The abstract makes note that 415 357 men were randomized in this trial, and that the study is on-going for long-term outcomes.
I think, especially among younger doctors, the pendulum has swung to far against PSA testing, now not being offered to many.
I think the problem lies in understanding the difference between a screening test and a diagnostic test.
By definition, a screening test applies to asymptomatic patients. If a man between 50 and 69 presents with any lower urinary tract symptoms or a change in voiding pattern, certainly a common scenario, he should be offered a PSA test as it is now no longer a screening test but a diagnostic test which is part of making an accurate diagnosis of his symptoms.
Dr. Glen Burgoyne.
I find this research more concerning than dis-satisfying. In terms of malpractice, what is the best course here? On the one hand, psa screening may admit to eventual harms. On the other hand not screening will admit to some very destructive cancers that might have been caught in time.
good poem
This study confirms my current practice of using the CTFPHC prostate cancer screening tool to discuss prostate cancer screening with patients.
Par contre , les urologues ne semblent pas encore au fait ou demeurent contre cette approche et les critiques sont virulentes concernant l’absence de dépistage . Heureusement, au Québec , l’age Du dépistage a été modifié à la hausse : 55 ans .