Opportunistic Prostate-specific Antigen Screening Research Articles

Young Age on Starting Prostate-specific Antigen Testing Is Associated with a Greater Reduction in Prostate Cancer Mortality: 24-Year Follow-up of the Göteborg Randomized Population-based Prostate Cancer Screening Trial

BackgroundThe risk of death from prostate cancer (PC) depends on age, but the age at which to start prostate-specific antigen (PSA) screening remains uncertain. ObjectiveTo study the relationship between risk reduction for PC mortality and age at first PSA screening. Design, setting, and participantsThe randomized Göteborg-1 trial invited men for biennial PSA screening between the ages of 50 and 70 yr (screening, n = 10 000) or no invitation but exposure to opportunistic PSA testing (control, n = 10 000). InterventionRegular versus opportunistic PSA screening or no PSA. Outcome measurements and statistical analysisWe modeled the nonlinear association between starting age and the absolute risk reduction in PC mortality in three settings: (1) intention-to-screen (randomized arms); (2) historical control (screening group and 1990–1994 registry data); and (3) attendees only (screening attendees and matched controls). We tested whether the effect of screening on PC mortality depends on the age at starting screening by comparing survival models with and without an interaction between trial arm and age (intention-to-screen and attendees only). Results and limitationsYounger age on starting PSA testing was associated with a greater reduction in PC mortality. Starting screening at age 55 yr approximately halved the risk of PC death compared to first PSA at age 60 yr. The test of association between starting age and the effect of screening on PC mortality was slightly greater than the conventional level of statistical significance (p = 0.052) for the entire cohort, and statistically significant among attendees (p = 0.002). This study is limited by the low number of disease-specific deaths for men starting screening before age 55 yr and the difficulty in discriminating between the effect of starting age and screening duration. ConclusionsGiven that prior screening trials included men aged up to 70 yr on starting screening, our results suggest that the effect size reported in prior trials underestimates that of currently recommended programs starting at age 50–55 yr. Patient summaryIn this study from the Göteborg-1 trial, we looked at the effect of prostate-specific antigen (PSA) screening in reducing men’s risk of dying from prostate cancer given the age at which they begin testing. Starting at a younger age reduced the risk of prostate cancer death by a greater amount. We recommend that PSA screening should start no later than at age 55 yr.

Clinical, pathological, and therapeutic features of newly diagnosed prostate cancer predominantly detected by opportunistic PSA screening: A survey of Shiga Prefecture, Japan

In all the prefectures of Japan, with the exception of Shiga Prefecture, more than half of local governments have an organized prostate-specific antigen (PSA) screening system in place. However, in the Shiga Prefecture, only a single city performed PSA screening over the time period of this survey. The purpose of the present study was to determine the clinical, pathological, and therapeutic features of newly diagnosed prostate cancer in localities where a formally organized screening system was almost entirely absent. A multicenter observational study was conducted in the Shiga Prefecture, which has the lowest rate of population-based PSA-screening in Japan. Patients' age, initial PSA, reasons for PSA testing, Gleason score, clinical stage, and primary treatments were surveyed. We stratified patients according to the reasons for PSA measurement, and compared the differences between groups subject to organized versus opportunistic screening. In the 2 years 2012 and 2017, 984 newly diagnosed prostate cancer patients were analyzed. Of these, 954 (97%) were opportunistically tested (i.e., not as part of an organized screening system), with the remaining 29 (3%) measured as part of an organized screening program. Patients in the former group exhibited a higher initial PSA value than in the organized screening group (median: 11.49 vs. 5.67 ng/ml). They also had worse clinical features, including higher Gleason score and TNM stage. More patients in the organized screening group were treated curatively than in the nonorganized screening group in terms of the primary treatment. The results were similar in a subanalysis of the patients of age 50-69 years. Organized PSA screening contributes to increasing the number of patients diagnosed with early-stage cancer who can be treated curatively.

Prostate-specific antigen testing and opportunistic prostate cancer screening: a cohort study in England, 1998-2017.

BackgroundProstate cancer is a leading cause of cancer- related death. Interpreting the results from trials of screening with prostate-specific antigen (PSA) is complex in terms of defining optimal prostate cancer screening policy.AimTo assess the rates of, and factors associated with, the uptake of PSA testing and opportunistic screening (that is, a PSA test in the absence of any symptoms) in England between 1998 and 2017, and to estimate the likely rates of pre-randomisation screening and contamination (that is, unscheduled screening in the ‘control’ arm) of the UK-based Cluster Randomised Trial of PSA Testing for Prostate Cancer (CAP).Design and settingOpen cohort study of men in England aged 40–75 years at cohort entry (1998–2017), undertaken using the QResearch database.MethodEligible men were followed for up to 19 years. Rates of PSA testing and opportunistic PSA screening were calculated; Cox regression was used to estimate associations.ResultsThe cohort comprised 2 808 477 men, of whom 631 426 had a total of 1 720 855 PSA tests. The authors identified that 410 724 men had opportunistic PSA screening. Cumulative proportions of uptake of opportunistic screening in the cohort were 9.96% at 5 years’, 22.71% at 10 years’, and 44.13% at 19 years’ follow-up. The potential rate of contamination in the CAP control arm was estimated at 24.50%.ConclusionA substantial number of men in England opt in to opportunistic prostate cancer screening, despite uncertainty regarding its efficacy and harms. The rate of opportunistic prostate cancer screening in the population is likely to have contaminated the CAP trial, making it difficult to interpret the results.

Prostate Cancer in Primary Care.

Prostate cancer is a common malignancy seen worldwide. The incidence has risen in recent decades, mainly fuelled by more widespread use of prostate-specific antigen (PSA) testing, although prostate cancer mortality rates have remained relatively static over that time period. A man’s risk of prostate cancer is affected by his age and family history of the disease. Men with prostate cancer generally present symptomatically in primary care settings, although some diagnoses are made in asymptomatic men undergoing opportunistic PSA screening. Symptoms traditionally thought to correlate with prostate cancer include lower urinary tract symptoms (LUTS), such as nocturia and poor urinary stream, erectile dysfunction and visible haematuria. However, there is significant crossover in symptoms between prostate cancer and benign conditions affecting the prostate such as benign prostatic hypertrophy (BPH) and prostatitis, making it very challenging to distinguish between them on the basis of symptoms. The evidence for the performance of PSA in asymptomatic and symptomatic men for the diagnosis of prostate cancer is equivocal. PSA is subject to false positive and false negative results, affecting its clinical utility as a standalone test. Clinicians need to counsel men about the risks and benefits of PSA testing to inform their decision-making. Digital rectal examination (DRE) by primary care clinicians has some evidence to show discrimination between benign and malignant conditions affecting the prostate. Patients referred to secondary care for diagnostic testing for prostate cancer will typically undergo a transrectal or transperineal biopsy, where a number of samples are taken and sent for histological examination. These biopsies are invasive procedures with side effects and a risk of infection and sepsis, and alternative tests such as multiparametric magnetic resonance imaging (mpMRI) are currently being trialled for their accuracy and safety in diagnosing clinically significant prostate cancer.

Prostate Cancer Mortality in Areas With High and Low Prostate Cancer Incidence

BackgroundThe effect of prostate-specific antigen (PSA) screening on prostate cancer mortality remains debated, despite evidence from randomized trials. We investigated the association between prostate cancer incidence, reflecting uptake of PSA testing, and prostate cancer mortality.MethodsThe study population consisted of all men aged 50 to 74 years residing in eight counties in Sweden with an early increase in prostate cancer incidence and six counties with a late increase during two time periods. Incidence of metastatic prostate cancer was investigated in the period from 2000 to 2009, and prostate cancer–specific mortality and excess mortality were investigated in the period from 1990 to 1999 and the period from 2000 to 2009 by calculating rate ratios for high- vs low-incidence counties and rate ratios for the period from 2000 to 2009 vs the period from 1990 to 1999 within these two groups. All statistical tests were two-sided.ResultsThere were 4528134 person-years at risk, 1577 deaths from prostate cancer, and 1210 excess deaths in men with prostate cancer in high-incidence counties and 2471373 person-years at risk, 985 prostate cancer deaths, and 878 excess deaths in low-incidence counties in the period from 2000 to 2009. Rate ratios in counties with high vs low incidence adjusted for time period were 0.81 (95% confidence interval [CI] = 0.73 to 0.90) for prostate cancer– specific mortality and 0.74 (95% CI = 0.64 to 0.86) for excess mortality, and the rate ratio of metastatic prostate cancer was 0.85 (95% CI = 0.79 to 0.92).ConclusionsThe lower prostate cancer mortality in high-incidence counties reflecting a high PSA uptake suggests that more-intense as compared with less-intense opportunistic PSA screening reduces prostate cancer mortality.

Opportunistic prostate-specific antigen screening in Italy: 6 years of monitoring from the Italian general practice database

The practice of prostate-specific antigen (PSA) screening has been increasing in Italy despite uncertain scientific evidence and contrary recommendations from most scientific societies. In 2002, a survey of PSA screening diffusion among general practices was performed, looking for screening frequency and age pattern of screened individuals. The objective of this study was to assess whether the features of PSA screening did change after 6 years in the same considered setting. Using the data obtained from 500 Italian general practitioners providing information to the Health Search/CSD Patient database, we selected, for the study purpose 351,091 male individuals. We assumed PSA prescriptions performed during 2005-2008 in individuals without prostate cancer, or benign prostate disease, or urological symptoms history to have a screening purpose. Screening frequency was analyzed in the overall series, by year and by patient's age. Exposure to PSA screening (at least on PSA test in the considered period) of males aged over 50 years raised from 31.4% (confidence interval 95% 31.08-31.70%) during 2002 to 46.4% (confidence interval 95% 46.19-46.68%) during 2008. The highest yearly exposure to PSA screening (55%) and the highest frequency of repeat testing was observed in the 70-79 age range. PSA screening practice has continued to increase in Italy and is often performed in elderly people without any scientific rationale.

Predictors of Successful Trial without Catheter in Acute Urinary Retention

Objectives: We aim to identify predictors of successful trial without catheter after an episode of acute urinary retention and to evaluate how serum prostate specific antigen (PSA) and C-reactive protein (CRP) levels behave during an acute urinary retention episode and also whether the PSA level is a useful indicator of undetected prostate cancer. Patients and methods: 335 patients presented to our institution in acute urinary retention from June 2006 to December 2007. After excluding females, patients with known prostate cancer, clot retention due to haematuria and catheter-related problems, 100 patients were entered into this prospective audit. On admission we documented serum PSA and CRP levels, residual urine volumes, urinary tract infection (UTI), digital rectal examination (DRE) and history of urinary tract surgery. The outcome of subsequent trial without catheter (TWOC) was documented. Where indicated, repeat serum PSA and CRP levels, transrectal ultrasound and prostate biopsies were obtained. Parametric and non-parametric tests were used for statistical analysis. Results: Median residual volume on catheterization was 750 mL. Successful TWOC was more likely in smaller sized prostates (Kendall tau-b, p = 0.004) and in benign feeling prostates (Fisher Exact Test, p = 0.004). TWOC failure was significantly higher in patients diagnosed with new prostate cancer (Fisher Exact Test, p = 0.032). Higher initial PSA levels, higher residual volumes and larger prostate size on DRE also resulted in higher TWOC failure rates. However these correlations were not statistically significant. UTI was confirmed in 13 of 100 patients on admission. Presence of UTI on admission had no influence on CRP or PSA levels, residual volumes or outcome of TWOC following treatment of UTI. Nine patients were diagnosed with prostate cancer of whom six had clinically significant cancer. On admission median serum PSA level was 7.0 ng/L (range 0.08–4624 ng/L) and median serum CRP level 21 mmol/L (range normal to 247 mmol/L). Serum PSA levels positively correlated with consecutive diagnosis of new prostate cancer. However when using 4 ng/L as the upper limit for normal PSA levels, sensitivity for detecting prostate cancer was 89%, specificity only 43% and positive predictive value 18%. Patients with a new diagnosis of prostate cancer had a high TWOC failure rate with eight of nine patients requiring re-catheterization. Neither PSA nor CRP levels were correlated with residual volumes, presence of UTI or prediction of TWOC outcome. Conclusions: Successful TWOC is more likely in smaller sized and benign feeling prostates. Neither PSA nor CRP levels help to predict TWOC outcome. Residual urinary volumes might be of little value in predicting TWOC outcome. Patients should therefore be given the ‘benefit of the doubt’ and offered TWOC regardless of large residual volumes. Patients presenting in AUR are at risk of harboring clinically significant prostate cancer. A high level of suspicion should remain especially in those with failed TWOC and normal DRE. Serum PSA is an unreliable marker to detect prostate cancer in this patient group. We therefore do not recommend opportunistic PSA screening during an AUR episode. CRP was not a good marker for prostatic infarction or inflammation.

PSA testing in Austria: induced morbidity and saved mortality

Opportunistic screening of healthy men by prostate-specific antigen (PSA) testing led to a steep increase of prostate cancer incidence in Austria. The objective of this study was to quantify how many additional men are diagnosed with prostate cancer by PSA testing, to save one man from prostate cancer death. Regression models for incidence and mortality for the time periods 1983-1991 and 1992-2003 by age groups 50-59 and 60-69 years were estimated. For 1992-2003, expected numbers of incidence and mortality were calculated. The first estimates for the years 1992-2003 were calculated using the regression model including the years 1983-1991. The second estimates were also calculated using the regression model, but including only the years 1992-2003. The difference between estimates was then summed up for 1992-2003. The corresponding sums of incidence and mortality were compared to provide estimates for the effect of the introduction of PSA screening on incidence/mortality ratio. According to our calculation for the time period 1992-2003, in age group 50-69 years, a total of 512 expected prostate cancer deaths were prevented because of opportunistic PSA screening, whereas PSA testing identified a total of 9648 additional men with asymptomatic prostate cancer. In conclusion, to save one man in the age group 50-69 years in the time period 1992-2003 from prostate cancer death by PSA testing, a total of 18.8 men with asymptomatic prostate cancer had to be identified. Although this study probably underestimates the benefit (reduced mortality) and overestimates excess incidence of prostate cancer, it is far from sure that in all of these additionally identified men prostate cancer would ever have surfaced as a clinical disease, if not screened for.

Men's reactions to disclosed and undisclosed opportunistic PSA screening for prostate cancer

To assess the degree to which men considered it appropriate for general practitioners to order prostate-specific antigen (PSA) testing if the testing was either "disclosed" or "undisclosed" to the patient. Telephone-administered survey conducted in June to October 2000. 514 men aged 50-70 years, identified by random selection of households from the Sydney Electronic White Pages phone directory. We developed two hypothetical scenarios. Each scenario described a GP ordering a PSA test for a male patient at the same time as other pathology tests were ordered. In Scenario 1, the GP's intention to order a PSA test was disclosed to the patient ("disclosed"). In Scenario 2, the GP did not tell the patient a PSA test was being ordered ("undisclosed"). For each scenario, men reported the degree to which they perceived screening to be "appropriate". We also recorded demographic characteristics, health status and health locus of control, and administered a 14-question knowledge test about prostate cancer and PSA screening. Over 90% of men stated that "disclosed" PSA screening was either "appropriate" or "very appropriate". Significantly fewer (44.9%) rated "undisclosed" screening as appropriate/very appropriate (P < 0.001). While the skewed distribution of responses to Scenario 1 precluded multivariate analysis to determine predictors, men rejecting "undisclosed" PSA screening (Scenario 2) were more likely to be younger (adjusted odds ratio [AOR], 0.97; 95% CI, 0.94-1.00; P = 0.03); to have better knowledge of the issues (AOR, 1.01; 95% CI, 1.00-1.03; P = 0.02); and to be single (AOR, 0.62; 95% CI, 0.41-0.94; P = 0.02). Many men consider that inclusion of PSA screening within a battery of pathology tests without disclosure to the patient is unacceptable. Educating men about the pros and cons of screening may alter their support of opportunistic screening and thus enhance community expectations of "informed participation".