Prostate cancer PSA screening: Jettisoning evidence-based medicine in favor of patient preference? "Only men who express a definite preference for screening should have PSA testing." (even though "no cancer-specific mortality benefit to PSA screening after 13-year follow-up")

JAMA. 2014 Mar 19;311(11):1143-1149.

Screening for Prostate Cancer With the Prostate-Specific Antigen Test: A Review of Current Evidence.

Hayes JH1, Barry MJ2.

Author information

• 1Dana-Farber Cancer Institute and Institute of Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
• 2Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

Abstract

IMPORTANCE Prostate cancer screening with the prostate-specific antigen (PSA) test remains controversial. 

OBJECTIVE To review evidence from randomized trials and related modeling studies examining the effect of PSA screening vs no screening on prostate cancer-specific mortality and to suggest an approach balancing potential benefits and harms. 

EVIDENCE ACQUISITION MEDLINE, EMBASE, and the Cochrane Register of Controlled Trials were searched from January 1, 2010, to April 3, 2013, for PSA screening trials to update a previous systematic review. Another search was performed in EMBASE and MEDLINE to identify modeling studies extending the results of the 2 large randomized trials identified. The American Heart Association Evidence-Based Scoring System was used to rate level of evidence. 

RESULTS Two trials-the Prostate, Lung, Colorectal and Ovarian (PLCO) screening trial and the European Randomized Study of Screening for Prostate Cancer (ERSPC)-dominate the evidence regarding PSA screening. The former trial demonstrated an increase in cancer incidence in the screening group (relative risk [RR], 1.12; 95% CI, 1.07-1.17) but no cancer-specific mortality benefit to PSA screening after 13-year follow-up (RR, 1.09; 95% CI, 0.87-1.36). The ERSPC demonstrated an increase in cancer incidence with screening (RR, 1.63; 95% CI, 1.57-1.69) and an improvement in the risk of prostate cancer-specific death after 11 years (RR, 0.79; 95% CI, 0.68-0.91). The ERSPC documented that 37 additional men needed to receive a diagnosis through screening for every 1 fewer prostate cancer death after 11 years of follow-up among men aged 55 to 69 years (level B evidence for prostate cancer mortality reduction). Harms associated with screening include false-positive results and complications of biopsy and treatment. Modeling studies suggest that this high ratio of additional men receiving diagnoses to prostate cancer deaths prevented will decrease during a longer follow-up (level B evidence). 

CONCLUSIONS AND RELEVANCE Available evidence favors clinician discussion of the pros and cons of PSA screening with average-risk men aged 55 to 69 years. Only men who express a definite preference for screening should have PSA testing. Other strategies to mitigate the potential harms of screening include considering biennial screening, a higher PSA threshold for biopsy, and conservative therapy for men receiving a new diagnosis of prostate cancer.