Effectiveness Of Prostate Cancer Screening Research Articles

The Japanese Guideline for Prostate Cancer Screening

In 2005, there were 9264 deaths from prostate cancer, accounting for 4.7% of the total number of cancer deaths in Japan. As the population continues to age, interest in prostate cancer screening has increased, and opportunistic screening for prostate cancer has been conducted worldwide. The guideline for prostate cancer screening was developed based on the established method. The efficacies of prostate-specific antigen (PSA) and digital rectal examination (DRE) were evaluated. Based on the balance of the benefits and harms, recommendations for population-based and opportunistic screening were formulated. Two methods of prostate cancer screening were evaluated. Based on the analytic framework involving key questions, 1186 articles published from January 1985 to October 2006 were selected using MEDLINE and other methods. After the systematic literature review, 28 articles were identified as providing evidence of mortality reduction from prostate cancer, including 5 observational studies for DRE screening, 1 meta-analysis, 3 randomized controlled trials and 19 observational studies for PSA screening. Although several studies showed that PSA screening had a beneficial effect, the results of the selected studies were inconsistent. Overall, the evidence that screening reduced mortality from prostate cancer was insufficient. Furthermore, prostate cancer screening is associated with serious harms, including overdiagnosis, adverse effects of needle biopsy and adverse effects of local prostatectomy. At present, the evidence for the effect of prostate cancer screening is insufficient. Both PSA and DRE were not recommended for population-based screening programs, but they could be conducted as individual-based screening if basic requirements were met.

Prostate cancer screening

Dear editor, We took great interest in reading the review [1] based on two randomized controlled trials on screening for prostate cancer. One of these is the ‘‘Norrkoping Study’’ conducted by our group [2]. Unfortunately, the name of the journal had been omitted (Eur Urol) in the reference list. As noted by the authors, the impact on the quality of life, associated harms or cost was not mentioned in the article. These issues, however, have been addressed in previous reports. Our screening trial was primarily designed to study the acceptability, costs, psychosocial consequences, and organisation [3]. Recently, we published a separate paper on costs and effects of prostate cancer screening in Sweden with 15 years follow-up including a decision model to calculate the total costs of the programme [4]. Introducing our screening programme in Sweden would incur 244 million SEK (265 million Euro) annually as additional costs for screening and treatment compared to a non-screening strategy.

Short report. The AIDIT and IMPACT conference 2006: Outcomes and future directions

IMPACT (Identification of Men with a genetic predisposition to ProstAte Cancer: Targeted screening in BRCA1/2 mutation carriers and controls) is an international collaboration investigating the utility of targeted prostate-specific antigen (PSA) screening for men at increased risk of prostate cancer due to inherited predisposition. Although the majority of prostate cancer occurs sporadically, it is recognized that family history plays a role in a significant number of cases: a family history either of prostate cancer alone [1], or of other cancers including breast and ovarian cancer [2]. Evidence of the link between single genes and prostate cancer risk is strongest for the BRCA1 and BRCA2 genes [3-5], with BRCA2 in particular thought to lead to a relative risk of 4.65 (95% CI 3.48-6.22). This relative risk may be as high as 7.33 in men under the age of 65 years. Population prostate cancer screening remains controversial because of the potential for detection of clinically insignificant disease in young men and the risk of over-treatment. There is increasing interest and concern in European countries about whether prostate cancer screening should be offered to the general population and whether this would lead to a reduction in mortality from prostate cancer. IMPACT raises the hypothesis that targeting screening at the men in the population who are known to have an increased risk of the disease might improve the effectiveness of prostate cancer screening. Beginning with a pilot of 100 patients, the IMPACT study ultimately aims to recruit a total of 850 carriers of mutations in BRCA1 and BRCA2 and 850 controls (men shown not to carry familial BRCA1/2 mutations by predictive genetic testing). Recruitment will be open for five years, followed by five years of follow-up. In 2005, a project known as AIDIT (Advancing International co-operation and Developing Infrastructure for Targeted screening of prostate cancer in men with genetic predisposition) was awarded funding through the EC Framework 6 Programme as part of an endeavour to reduce research fragmentation and duplication, and to facilitate research collaboration across Europe. IMPACT currently includes collaborators from 24 countries. AIDIT's aim is to expand the IMPACT consortium within the associated candidate countries (ACCs) and new member states of the EU. The expansion of IMPACT is likely to benefit both the study and the research teams: a higher number of collaborating centres will allow access to a larger number of men at risk, making it possible to recruit as many carriers as are needed for the study, particularly in populations likely to harbour founder mutations; and for all collaborators - both new and existing - it is hoped that participation in AIDIT and IMPACT will foster an environment of ongoing interaction and learning.

Benefit evaluation of mass screening for prostate cancer: Willingness-to-pay measurement using contingent valuation

Objectives Cancer screening exists to save lives. However, the mortality-reducing effect of prostate cancer screening has not yet been sufficiently demonstrated. Therefore, screening should only be performed in men well informed about the disease. We hypothesized that having sufficient information will reduce men’s desire for screening. To verify this hypothesis, we measured the willingness to pay (WTP) for prostate-specific antigen screening using the contingent valuation method. Methods A computer-based questionnaire was implemented through the Internet for 137 men in Japan aged 40 to 59 years. Participants were randomly assigned to two subgroups: 69 subjects were provided with information about the detection rate, and 68 were provided with additional information such as the failure to demonstrate the mortality-reducing effect of prostate-specific antigen screening to date. All were asked about their WTP by a payment cards approach. Results The mean WTP for prostate-specific antigen screening was $18.90. Categorical regression analysis suggested that annual income, age, and hospitalization history were factors affecting the WTP. Unexpectedly, the difference in the mean WTP between the ill-informed and well-informed groups was not statistically significant. Conclusions The contingent valuation method can quantify comprehensive benefits, including not only health outcomes, but also non-health outcomes such as reassurance value. The subjects were not so concerned about the long-term effectiveness of saving lives. Their greatest concern was the detection rate. Their WTP may have reflected their desire for the reassurance that could be obtained by confirming that they had no physical sign of cancer.

Urban–rural differences in prostate cancer mortality, radical prostatectomy and prostate‐specific antigen testing in Australia

To assess differences in trends for prostate cancer mortality, radical prostatectomy and prostate-specific antigen (PSA) testing for Australian men aged 50-79 years living in capital cities compared with regional and rural areas. Descriptive, population-based study based on data from official sources from 1985 to the 2002/03 financial year (depending on data availability). Age-standardised rates per 100,000 men aged 50-79 years of mortality from prostate cancer, incidence of prostate cancer, PSA tests and radical prostatectomy. We found a statistically significant and increasing (age-standardised) mortality excess for prostate cancer in regional and rural areas. In 2000-2002 the excess (compared with capital cities) was 21% (95% CI, 14%-29%). Rates of radical prostatectomy in rural and regional Australia were 29% lower (95% CI, 23% lower to 35% lower) than in capital cities. Although PSA testing is common across the whole of Australia, age-standardised rates in 2002/03 were 16% lower (95% CI, 15% lower to 17% lower) in regional and rural areas than in capital cities. Our results show that the probability of a man having a PSA test and the management of his prostate cancer depend on where he lives. The cause or causes of the prostate cancer mortality excess in regional/rural areas cannot be established in a descriptive study, but fewer radical prostatectomies in regional and rural areas, perhaps associated with less PSA screening, remain among the several competing hypotheses. Other possibilities are related to other differences in management, perhaps associated with access to urologists. Governments and other budget holders need good evidence about the effectiveness of prostate cancer screening and early treatment, but also about the best strategies for providing equitable access to cancer services in both urban and rural areas.

Update on screening and early detection of prostate cancer.

The aim of this review is to discuss advances in the field of screening and early detection of prostate cancer from papers published in 2003. The fall in distant prostate cancer mortality accounted for the overall decline in cause-specific mortality rates in the USA. In the European prostate cancer screening trial (European Randomized Study of Screening for Prostate Cancer), there is considerable stage migration towards organ-confined disease, which becomes more pronounced in the second screening round. The high sensitivity of the screening protocol (approximately 90%), low interval cancer rate (13-19%) and lead time estimates of 10 years and longer support a 4-year screening interval, current procedure in the European Randomized Study of Screening for Prostate Cancer trial. Advances achieved in research on the discriminative power of the free prostate-specific antigen forms, particularly pro-prostate-specific antigen, have progressed and may be introduced in cancer detection at low prostate-specific antigen levels rather than a further reduction of the current prostate-specific antigen threshold. Definitive evidence on the effectiveness of prostate cancer screening with prostate-specific antigen should come from the ongoing European Randomized Study of Screening for Prostate Cancer and Prostate, Lung, Colorectal and Ovary cancer trials, and should further elucidate the debate about the appropriate prostate-specific antigen threshold. Free prostate-specific antigen sub-forms offer prospects for prostate cancer detection at low prostate-specific antigen levels.

Costs and effects of prostate cancer screening in SwedenA 15-year follow-up of a randomized trial

To estimate the lifetime cost per detected potentially curable cancer and the economic impact on healthcare of repeated screening for prostate cancer in Sweden in a cohort of men aged 50-69 years. All 9171 men in a geographically defined population were included: 1492 were randomized to screening in four rounds every third year and 7679 constituted a control group. Digital rectal examination and prostate-specific antigen screening in different combinations were used as diagnostic measures. Costs associated with administration of the screening programme, loss of patient time, diagnostic measures and management strategies were included. A decision model was developed to calculate the total cost of the programme. The incremental cost per extra detected localized cancer was 168,000 SEK and per potentially curable cancer 356,000 SEK. Introducing this screening programme for prostate cancer in Sweden would incur 244 million SEK annually in additional costs for screening and treatment compared to a non-screening strategy. There is still no scientific evidence that patients will benefit from screening programmes. Prostate cancer screening would probably be perceived as cost-effective if potentially curable patients gained on average at least 1 year of survival.

Including the quality-of-life effects in the evaluation of prostate cancer screening: expert opinions revisited?

To apply the general empirical framework for estimating utilities in cost-utility analysis (CUA) of population-based prostate cancer screening, including an assessment of empirical health status with a classifying measure (e.g. the EQ-5D) and linking these descriptions to utility estimates using the standard preference-based algorithm, combining them with the appropriate duration into quality-adjusted life years, and sensitivity analysis. Empirical studies to describe and value the health status effects of prostate cancer screening have been ongoing within the Rotterdam centre of the European Randomised Study on Screening for Prostate Cancer since 1995. The results of these studies, including the screening, the primary treatment phase and advanced disease, will be used in estimating utilities for cost-utility analysis. Estimation of cost-utility of population-based prostate cancer screening with the results of the three empirical health status studies yielded partly counterintuitive results, underestimating the unfavourable health status effects that are inevitably associated with prostate cancer screening. This may be caused by other than health effects of the screening itself ('process effects') and adaptive changes in perception of their situation in patients after curative primary treatment ('response shift'), among other elements. These results prompted us to reconsider the suitability of the general framework of CUA for screening programmes. Possible directions for solutions are indicated.

Health technology assessment and implications for clinical practice: the case of prostate cancer screening

We describe an initiative to disseminate evidence from systematic reviews about the clinical effectiveness of prostate cancer screening to general practitioners and urologists in Norway. The Norwegian Centre for Health Technology Assessment invited The Norwegian Medical Association, The Norwegian Cancer Society, The Norwegian Board of Health, The Norwegian Urological Cancer Group and The Norwegian Patient Association to develop and disseminate clinical practice recommendations. The clinical effectiveness of prostate cancer screening has been assessed in nine independent systematic reviews, which are summarized in a joint INAHTA report. The conclusion was that there is no evidence from appropriately designed trials that early detection and treatment of prostate cancer can reduce mortality, morbidity or improve quality of life. The number of prostate‐specific antigen (PSA) tests analysed in Norway increased by 30% from 1996 to 1999; at the county level the increase ranged from 12 to 48%. On this background we disseminated leaflets with information about PSA and prostate cancer to 4100 general practitioners and specialists in urology. The main message was, i) PSA should not be taken in healthy men, ii) if the test is wanted, the physician is obliged to give information about the possible consequences. Despite efforts to anchor the information campaign within the mentioned organizations, this met with notable opposition from The Norwegian Urological Society. A survey among agencies within the INAHTA network showed that more than half of the countries within this collaboration have implemented guidelines or recommendations on prostate cancer screening. In conclusion, evidence obtained through an international collaboration such as the INAHTA collaboration may be used to develop and implement national guidelines or recommendations.

Effectiveness of mass screening for the prognosis of prostate cancer patients in Japanese communities

BACKGROUND A study was conducted to investigate the effectiveness of mass screening (MS) for prostate cancer in Japanese communities using the long-term follow-up results. METHODS Subjects were 279 patients with prostate cancer detected by MS in Gunma prefecture (MS group) and 624 patients with prostate cancer who did not undergo screening (non-MS group). From the follow-up data, the prognoses were compared between the groups. RESULTS The ratio of patients with Stage II cancer was higher for the MS group (59.1%) when compared to non-MS group (25.3%). As a whole, the prognosis of the MS group was more favorable than that of the non-MS group for relative survival rate. Prognosis was especially favorable for patients with Stage III prostate cancer in mass screening group considering the effect of lead-time bias. CONCLUSIONS Early detection and longer survival of the patients with prostate cancer detected by mass screening suggested the effectiveness of prostate cancer screening. Prostate 50: 262–269, 2002. © Wiley-Liss, Inc.

Prostate cancer screening: promise and peril--a review.

This review summarizes the current status of and recommendations for prostate cancer screening with prostate-specific antigen in light of recent reductions in prostate cancer incidence and mortality. It describes how the uncertain effectiveness of aggressive treatment for prostate cancer and a reservoir of unsuspected indolent cancers make prostate cancer fit poorly into conventional screening models. The large proportion of men with unsuspected prostate cancers that may not cause morbidity or mortality and are unlikely to benefit from aggressive treatment decrease the effectiveness of a screening program. In addition, indolent, unsuspected prostate cancers in the screening population accentuate the detrimental effects of length bias on studies evaluating the effectiveness of prostate cancer screening. Screening tests for prostate cancer will continue to improve, but chemoprevention or nutritional prevention with vitamins and micronutrients such as tocopherols or selenium may prove to be effective methods of reducing prostate cancer incidence and should be aggressively investigated.

Short-term effects of population-based screening for prostate cancer on health-related quality of life.

Population-based screening for prostate cancer is currently being evaluated in randomized clinical trials in the United States and in Europe. Side effects arising from the process of screening and from the earlier treatment of screen-detected prostate cancer may be important factors in the evaluation. To examine health-related quality of life (or health status) among men screened for prostate cancer, we conducted a longitudinal study of 626 attenders to the Rotterdam (The Netherlands) prostate cancer screening program and of 500 nonparticipants. Attenders of the screening program and nonparticipants completed self-assessment questionnaires (SF-36 [i.e., Medical Outcomes Study 36-Item Short-Form Health Survey] and EQ-5D [i.e., EuroQol measure for health-related quality of life] health surveys) to measure generic health status, as well as an additional questionnaire for anxiety and items relating to prostate cancer screening. Physical discomfort during digital rectal examination and during transrectal ultrasound was reported by 181 (37%) of 491 men and by 139 (29%) of 487 men, respectively; discomfort during prostate biopsy was reported by 64 (55%) of 116 men. Mean scores for health status and anxiety indicated that the participants did not experience relevant changes in physical, psychological, and social functioning during the screening procedure. However, high levels of anxiety were observed throughout the screening process among men with a high predisposition to anxiety. Similar scores for anxiety predisposition were observed among attenders and nonparticipants. At the group level, we did not find evidence that prostate cancer screening induced important short-term health-status effects, despite the short-lasting side effects related to the biopsy procedure. However, subgroups may experience high levels of anxiety. The implication is that unfavorable health-status effects of prostate cancer screening occur mainly in the treatment phase.

THE SOCIOECONOMIC IMPLICATIONS OF PROSTATE-SPECIFIC ANTIGEN SCREENING

Widespread PSA screening will increase overall health care costs. This increase will not result from the detection of clinically insignificant prostate cancer, but rather from the stage migration caused by prostate cancer screening. This stage migration will result in a larger percentage of men with prostate cancer undergoing early treatment options, which are more expensive than treatment of late disease. More importantly, early detection of prostate cancer will lead to treatment several years earlier than would have occurred otherwise. Because treatment then will be paid for in current rather than future dollars, the opportunity costs of money will make treatment costs resulting from PSA screening greater than treatment costs resulting from traditional detection. The critical question is what benefits will be obtained by the expenditure of these additional health care dollars. If early treatment of clinically localized cancer has little or no effect on cause-specific survival, the additional health care costs will have been spent only to limit eventual treatment of local symptoms in the screened men. If early treatment of prostate cancer can increase survival, the added expense is more worthwhile. Because there are not adequate data available to address this issue, several approaches have been used to develop models to estimate cost-effectiveness. Decision analysis models have been used to evaluate the effectiveness of prostate cancer screening and treatment and have found little or no benefit. The current review has demonstrated how assumptions used in the models can influence the results. Benoit et al also have constructed a model of the effectiveness and cost-effectiveness of prostate cancer, but in this study only concrete parameters such as cost, published complication rates, and survival data were used. This quantitative analysis demonstrated that prostate cancer screening is an effective and cost-effective health care intervention compared with currently accepted medical interventions. Although men aged 50 to 70 years will potentially benefit the most from PSA screening, this benefit will not be realized until these men are in their seventh and eighth decades of life. Society must decide if the years of life saved in these men warrants the use of its limited health care resources. This decision will be easier when randomized, controlled trials are available to quantify the costs and benefits of PSA screening.

Should medicare provide reimbursement for prostate-specific antigen testing for early detection of prostate cancer? Part II: Early detection strategies

This article represents Part II of a four-part policy analysis that will be published over 4 consecutive months. The articles are based on a background article originally prepared for the Office of Technology Assessment of the United States Congress, which has released its own report on the costs and effectiveness of prostate cancer screening among Medicare-aged men. The four parts will frame the debate, review early detection strategies for prostate cancer, review management strategies, and estimate the risks, benefits, and costs of an early detection program among older men. This article represents Part II of a four-part policy analysis that will be published over 4 consecutive months. The articles are based on a background article originally prepared for the Office of Technology Assessment of the United States Congress, which has released its own report on the costs and effectiveness of prostate cancer screening among Medicare-aged men. The four parts will frame the debate, review early detection strategies for prostate cancer, review management strategies, and estimate the risks, benefits, and costs of an early detection program among older men.