Screening for Prostate Cancer: Current Status and Future Directions

Abstract

Population-based prostate-specific antigen (PSA) screening for prostate cancer has become a heated health policy issue in recent years, and a thorough understanding of this complex narrative is essential to ensure progress and innovation as we move forward. In this issue of European Urology Focus, van den Bergh and coauthors [1] present an insightful review of the impact of early diagnosis of prostate cancer via PSA-based screening, and provide both a broader overview of population-based trends in disease characteristics and a nuanced analysis of the two landmark screening trials, the Prostate, Lung, Colorectal, and Ovarian (PLCO) cancer screening trial [2] and the European Randomized Study of Screening for Prostate Cancer (ERSPC) [3]. As the authors describe, data support both a significant stage migration and a mortality reduction since the introduction of PSA screening in the 1990s. For instance, the proportion of men presenting with metastatic disease has decreased from approximately 1 in 3 in the 1980s to 4% from 2004 to 2010 [1,4] and prostate cancer mortality has decreased, with an estimated 45–70% of the decline attributed to screening [5]. Yet despite promising trends in population-based data, the two randomized screening trials have, at first glance, failed to demonstrate the anticipated mortality reduction: PLCO noted no benefit of screening and ERSPC revealed a mortality reduction of 21% over 13-yr follow-up. However, ‘‘absence of evidence is not evidence of absence,’’ and an accurate interpretation of these studies requires a more nuanced analysis. As the authors emphasize, the two studies had significant rates of contamination and noncompliance, both of which would mitigate any screening benefits. As an example, the estimated mortality reduction in ERSPC would increase to as high as 51% after