Redesigning Prostate Cancer Screening Strategies to Reduce Overdiagnosis

Abstract

It is remarkable that even though 30 years have passed since the introduction of prostate-specific antigen (PSA)2 into US clinical practice, researchers and clinicians are still debating its value for prostate cancer screening. The US Preventive Services Task Force has seesawed from stating that PSA testing was a personal decision for the individual man in 2008, to concluding “moderate or high certainty that … the harms outweigh the benefits” in 2012, to recommending shared decision-making once again in 2018 (1). In most industrialized countries, government-sanctioned guideline groups recommend against population-based screening, yet PSA testing remains common in everyday practice throughout the Western world. My own view is that the PSA debate has lost the forest for the trees. White papers and recommendation statements focus on subtle points of scientific methodology—such as whether postrandomization consent results in the loss of allocation concealment—while giving sparse attention to some larger facts and principles. Here, I lay out 3 simple, established, and accepted propositions about PSA screening and argue that these lead to some straightforward conclusions. For many years, it was open to reasonable debate as to whether PSA screening did, in fact, reduce prostate cancer mortality. Recent data have ended this debate. There has been only 1 methodologically acceptable randomized trial of PSA screening, the European Randomised Study of Screening for Prostate Cancer (ERSPC), and this trial clearly showed a reduction in prostate cancer mortality (2). Similarly, recent US population trends showing reductions of 40% to 50% in prostate cancer mortality since the pre-PSA era cannot be explained without reference to a screening effect (3). The harms of PSA screening, on the other hand, are well known. Prostate cancer generally has a very indolent course, such that a large proportion of screen-detected cancers would never have been diagnosed during the patient's …