Prostate-specific Antigen Screening For Prostate Cancer Research Articles

The Association of County-level Prostate-specific Antigen Screening with Metastatic Prostate Cancer and Prostate Cancer Mortality

Background and objectiveThere exists ongoing debate about the benefits and harms of prostate-specific antigen (PSA) screening for prostate cancer. This study sought to evaluate the association of county-level PSA screening rates with county-level incidence of metastatic prostate cancer and prostate cancer mortality in the USA. MethodsThis ecological study used data from the 2004–2012 Behavioral Risk Factor Surveillance System (BRFSS) to build a multilevel mixed-effect model with poststratification using US Census data to estimate county-level PSA screening rates for all 3143 US counties adjusted for age, race, ethnicity, and county-level poverty rates. The exposure of interest was average county-level PSA screening rate from 2004 to 2012, defined as the proportion of men aged 40–79 yr who underwent PSA screening within the prior 2 yr. The primary outcomes were county-level age-adjusted incidence of regional/distant prostate cancer during 2015–2019 and age-adjusted prostate cancer mortality during 2016–2020. Key findings and limitationsA total of 416221 male BRFSS respondents aged 40–79 yr met the inclusion criteria and were used in the multilevel mixed-effect model. The model was poststratified using 63.4 million men aged 40–79 yr from all 3143 counties in the 2010 Decennial Census. County-level estimated PSA screening rates exhibited geographic variability and were pooled at the state level for internal validation with direct BRFSS state-level estimates, showing a strong correlation with Pearson correlation coefficients 0.77–0.90. A 10% higher county-level probability of PSA screening in 2004–2012 was associated with a 14% lower county-level incidence of regional/distant prostate cancer in 2015–2019 (rate ratio 0.86, 95% confidence interval [CI] 0.85–0.87, p < 0.001) and 10% lower county-level prostate cancer mortality in 2016–2020 (rate ratio 0.90, 95% CI 0.89–0.91, p < 0.001). Conclusions and clinical implicationsIn this population-based ecological study of all US counties, higher PSA screening rates were associated with a lower incidence of regional/distant prostate cancer and lower prostate cancer mortality at extended follow-up. Patient summaryUS counties with higher rates of prostate-specific antigen (PSA) screening had significantly lower rates of metastatic prostate cancer and prostate cancer mortality in subsequent years. These data may inform shared decision-making regarding PSA screening for prostate cancer.

Prostate cancer screening-current overview

The harm-to-benefit ratio of prostate cancer (PCa) screening remains controversial mainly due to the unfavorable test characteristics of prostate-specific antigen (PSA) as ascreening test. In this nonsystematic review, we present acurrent overview of the body of evidence on prostate cancer screening with afocus on the role of magnetic resonance imaging (MRI) of the prostate. Evidence generated in large randomized controlled trials showed that PSA-based screening significantly decreases cancer-specific mortality. The main obstacle in developing and implementing PCa screening strategies is the resulting overdiagnosis and as aconsequence overtreatment of indolent cancers. Opportunistic screening is characterized by an adverse benefit-to-harm ratio and should, therefore, not be recommended. The German Statutory Early Detection Program for prostate cancer, which consists of adigital rectal examination (DRE) as astand-alone screening test, is not evidence-based, neither specific nor sensitive enough and results in unnecessary diagnostics. The European Commission recently urged member states to develop population-based and organized risk-adapted PSA-based screening programs, which are currently tested in the ongoing German PROBASE trial. Finetuning of the diagnostic pathway following PSA-testing seems key to improve its positive and negative predictive value and thereby making PCa screening more accurate. Incorporation of prostatic MRI into screening strategies leads to more accurate diagnosis of clinically significant prostate cancer, while diagnosis of indolent cancers is reduced. In the future, molecular liquid-based biomarkers have the potential to complement or even replace PSA in PCa screening and further personalize screening strategies. Active surveillance as an alternative to immediate radical therapy of demographically increasing PCa diagnoses can potentially further improve the benefit-to-harm ratio of organized screening. Early detection of PCa should be organized on apopulation level into personalized and evidence-based screening strategies. Multiparametric MRI of the prostate may play akey role in this setting.

Prostate Cancer Foundation Screening Guidelines for Black Men in the United States

BackgroundIn the United States, Black men are at highest risk for being diagnosed with and dying from prostate cancer. Given this disparity, we examined relevant data to establish clinical prostate-specific antigen (PSA) screening guidelines for Black men in the United States.MethodsA comprehensive literature search identified 1848 unique publications for screening. Of those screened, 287 studies were selected for full-text review, and 264 were considered relevant and form the basis for these guidelines. The numbers were reported according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.ResultsThree randomized controlled trials provided Level 1 evidence that regular PSA screening of men 50 to 74 years of age of average risk reduced metastasis and prostate cancer death at 16 to 22 years of follow-up. The best available evidence specifically for Black men comes from observational and modeling studies that consider age to obtain a baseline PSA, frequency of testing, and age when screening should end. Cohort studies suggest that discussions about baseline PSA testing between Black men and their clinicians should begin in the early 40s, and data from modeling studies indicate prostate cancer develops 3 to 9 years earlier in Black men compared with non-Black men. Lowering the age for baseline PSA testing to 40 to 45 years of age from 50 to 55 years of age, followed by regular screening until 70 years of age (informed by PSA values and health factors), could reduce prostate cancer mortality in Black men (approximately 30% relative risk reduction) without substantially increasing overdiagnosis.ConclusionsThese guidelines recommend that Black men should obtain information about PSA screening for prostate cancer. Among Black men who elect screening, baseline PSA testing should occur between ages 40 and 45. Depending on PSA value and health status, annual screening should be strongly considered. (Supported by the Prostate Cancer Foundation.)

Prostate Cancer Screening Uptake in Transgender Women

There is no consensus in prostate-specific antigen (PSA) screening guidelines regarding transgender women despite their known prostate cancer risk. To identify factors associated with recent (within the last 2 years) PSA screening in transgender women compared with cisgender men. This case-control study used data from the 2018 and 2020 Behavioral Risk Factor Surveillance System (BRFSS) surveys to characterize rates of PSA screening for prostate cancer within the past 2 years and multivariable logistic regressions to characterize factors associated with recent screening among transgender women. The BRFSS program of the Centers for Disease Control and Prevention annually surveys over 400 000 US adults on behavioral risk factors, chronic illnesses, and use of preventive services. Respondents to the BRFSS who were cisgender men or transgender women 40 years or older and who had complete PSA testing responses and no prostate cancer history were included; 313 transgender women and 138 937 cisgender men met inclusion criteria. Matching was performed by age, race and ethnicity, educational level, employment, annual income, survey year, and cost barriers to care. Data were collected on November 2, 2022, and analyzed from November 2, 2022, to December 3, 2023. Rates of and factors associated with recent PSA screening in transgender women. Among the 1275 participants included in the matched cohort (255 transgender women and 1020 cisgender men; 570 [44.7%] aged 55-69 years), recent PSA screening rates among transgender women and cisgender men aged 55 to 69 were 22.2% (n = 26) and 36.3% (n = 165), respectively; among those 70 years and older, these rates were 41.8% (n = 26) and 40.2% (n = 98), respectively. In the matched cohort, transgender women had lower univariable odds of recent screening than cisgender men (odds ratio [OR], 0.65 [95% CI, 0.46-0.92]; P = .02). In a hierarchical regression analysis adding time since the last primary care visit, effect size and significance were unchanged (OR, 0.61 [95% CI, 0.42-0.87]; P = .007). After adding whether a clinician recommended a PSA test, there was no statistically significant difference in odds of screening between transgender women and cisgender men (OR, 0.83 [95% CI, 0.45-1.27]; P = .21). The results were further attenuated when clinician-led discussions of PSA screening advantages and disadvantages were added (OR, 0.87 [95% CI, 0.47-1.31]; P = .32). In a multivariable logistic regression among transgender women, having a recommendation for PSA testing was the factor with the strongest association with recent screening (OR, 12.40 [95% CI, 4.47-37.80]; P < .001). In this case-control study of one of the largest cohorts of transgender women studied regarding PSA screening, the findings suggest that access to care or sociodemographic factors were not principal drivers of the screening differences between transgender women and cisgender men; rather, these data underscore the clinician's role in influencing PSA screening among transgender women.

Risk-stratified multi-round PSA screening for prostate cancer integrating the screening reference level and subgroup-specific progression indicators

BackgroundAlthough prostate-specific antigen (PSA) is widely used in prostate cancer (PCa) screening, nearly half of PCa cases are missed and less than one-third of cases are non-lethal. Adopting diagnostic criteria in population-based screening and ignoring PSA progression are presumed leading causes.MethodsA total of 31,942 participants with multi-round PSA tests from the PLCO trial were included. Time-dependent receiver-operating-characteristic curves and area under curves (tdAUCs) were performed to determine the screening reference level and the optimal subgroup-specific progression indicator. Effects of risk-stratified multi-round PSA screening were evaluated with multivariable Cox regression and measured with hazard ratio [HR (95%CIs)].ResultsAfter a median follow-up of 11.6 years, a total of 3484 PCa cases and 216 PCa deaths were documented. The tdAUC of 10-year incidence PCa with PSA was 0.816, and the cut-off value was 1.61 ng/ml. Compared to subgroup with stable negative PSA in both first-round (FR) and last-round (LR) tests [FR(−)/LR(−)], HRs (95%CI) of PCa incidence were 1.66 (1.20–2.29), 8.29 (7.25–9.48), and 14.52 (12.95–16.28) for subgroups with loss of positive PSA[FR(+)/LR(−)], gain of positive PSA[FR(−)/LR(+)], and stable positive PSA[FR(+)/LR(+)]; while HRs(95%CI) of PCa mortality were 1.47 (0.52–4.15), 5.71 (3.68–8.86), and 5.01 (3.41–7.37). After excluding regressive PSA [(namely FR(+)/LR(−)], absolute velocity was the shared optimal progression indicator for subgroups with FR(−)/LR(−), FR(−)/LR(+), and FR(+)/LR(+), with tdAUCs of 0.665, 0.681 and 0.741, and cut-off values of 0.07, 0.21, and 0.33 ng/ml/year. After reclassifying participants into groups with positive and negative progression based on subgroup-specific progression indicators, incidence HR (95%CI) were 2.41 (1.87–3.10), 2.91 (2.43–3.48), and 3.16 (2.88–3.46) for positive progression compared to negative progression within subgroups of FR(−)/LR(−), FR(−)/LR(+), and FR(+)/LR(+), while mortality HR (95%CI) were 2.22 (0.91–5.38), 2.37 (1.28–4.38), and 2.98 (1.94–4.59). To improve screening performances by excluding regressive PSA and low-risk positive progression in FR(−)/LR(−), optimized screening strategy not only significantly reduce 32.4% of missed PCa (54.0% [1881/3484] vs. 21.6% [754/3484], P < 0.001), but also detected additional 8.0% of high-grade PCa (Gleason score 7–10: 36.0% [665/1849] vs. 28.0% [206/736], P < 0.001) than traditional screening strategy.ConclusionsRisk-stratified multi-round PSA screening strategy integrating the screening reference level and the optimal subgroup-specific progression indicator of PSA could be recommended as a fundamental strategy to reduce missed diagnosis and improve the detection of high-grade PCa cases.

Screening Asymptomatic Men for Prostate Cancer Using Prostate-Specific Antigen as An Early Detection Tool: A Review of Existing Literature

Prostate cancer remains the most common non-skin cancer in men. Prostate-specific antigen (PSA) is recognized as a biomarker for the diagnosis, monitoring, and risk prediction of prostate cancer. However, its role in prostate cancer screening has been controversial. While some authorities have recommended its use for screening, others have stated otherwise. Some clarity is required about its precise role in clinical practice. There need to be more consistent recommendations surrounding using PSA screening in clinical practice. Serum PSA measurements show variable reliability when screening for Prostate cancer, given the dynamics of PSA physiology and the conflicting results from two large, randomized control trials that sought to determine its role in prostate cancer screening and early detection. Hence surrogate measures like PSA density, PSA velocity, free-to-complexed PSA ratio, and percentage Pro-PSA among others, have been used to improve the predictive utility of this assay for Prostate cancer diagnosis. However, the debate on screening still lingers. The current review aims to highlight the controversies and objectively outline the current recommendations. This literature review examined scholarly papers and recommendations about the use of PSA for prostate cancer screening with the aim to rationalize the pros and cons of such approaches. We concluded that although more recent guidelines from the USPSTF recommend that screening be based on individual preference and professional judgment by the healthcare provider, differences in the specific details on how to best employ a PSA screening program still exist and require further review.

The association between clinically determined periodontal disease and prostate-specific antigen concentration in men without prostate cancer: the 2009-2010 National Health and Nutrition Examination Survey.

We evaluated the association between clinically assessed periodontal disease and serum prostate-specific antigen (PSA) concentration in men without a prostate cancer diagnosis in a US nationally representative sample of non-institutionalized men. Included were 1263 men aged ≥ 40years who participated in the National Health and Nutrition Examination Survey in 2009-2010. Measurements of periodontal health and tooth count were used to define periodontal disease severity (no, mild, moderate, severe) and edentulism. Linear and logistic regressions were used to estimate the association of periodontal disease severity and edentulism with PSA concentration and elevated PSA, respectively. Adjusting for age and other factors including race, body mass index, and education, the natural logarithm of PSA concentration did not change with increasing severity (mild - 0.20, 95% confidence interval [CI] - 0.34 to - 0.05; moderate - 0.12, 95% CI - 0.26 to 0.01; severe - 0.16, 95% CI - 0.43 to 0.12; edentulism - 0.16, 95% CI - 0.35 to 0.04; P-trend 0.13) compared with dentate men without periodontal disease. Although the multivariable-adjusted ORs of elevated PSA were not statistically significant, participants with more severe periodontal disease were less likely to have PSA > 2.0 and > 2.5ng/mL, but more likely to have PSA > 4.0ng/mL, compared to dentate men without periodontal disease. Similar non-significant associations with PSA were observed when comparing edentulous men to dentate men without periodontal disease. In this US nationally representative sample, men with periodontal disease did not have higher serum PSA and were not more likely to have clinically elevated PSA after taking into account age and other factors, contrary to the hypothesis. This study suggests that periodontal disease does not notably affect the specificity of PSA for prostate cancer screening.

The novel biomarkers in diagnosis of prostate cancer

The prostate specific antigen (PSA) as a biomarker for prostate cancer (PCa) diagnosis has been widely used in the clinic for several decades. However, PSA has a low specificity for PCa diagnosis, thereby several gene, blood and urine-based biomarkers (such as sarcosine) underlying biology of PCa progression are being developed to improve the accuracy of PCa diagnosis. In the present review, we focus on novel PCa biomarkers, which are ptentially superior to PSA in PCa screening and facilitate clinical PCa diagonosis. The early PCa screening with reliable biomarkers is critical in reducing the mortality of clinical PCa (high-risk PCa). For clinical insignificant PCa (low-risk PCa) patients and benign prostatic hyperplasia patients, biopsies should be avoided and disease progression should be monitored by using non-invasive biomarkers.

PSA Screening for Prostate Cancer in Men under the Age of 65: A Review of Current Practice

Purpose: To review current practice in the use of Prostate Specific Antigen (PSA) testing and assess the overall risks and benefits of PSA testing for Adenocarcinoma of the Prostate, specifically in men under age 65, and those living with risk factors for the disease. Materials and Methods: An extensive literature review of PSA testing in various age groups was conducted with the goal being to review PSA screening trends and assess current recommendations regarding PSA Screening for Adenocarcinoma of the Prostate in various age groups, focusing on studies directed towards patients under the age of 65 and the long-term risks and benefits of PSA screening in the diagnostic algorithm. In order to reduce bias, we assessed our sources for variables such as reporting, measurement and/or selection bias. Our conclusions were then compared with current recommendations. Relevant studies with data compiled after 2004, centered around PSA screening in men under the age of 65 in general and specifically in men with risk factors for developing Adenocarcinoma of the Prostate were included. Editorials, newspaper articles and other non-scholarly and non-peer reviewed sources were automatically excluded.

PSA screening for prostate cancer.

Screening of prostate cancer with prostate-specific antigen (PSA) is a highly controversial issue. One part of the controversy is due to the confusion between population screening and early diagnosis, another derives from problems related to the quality of existing screening studies, the results of radical curative treatment for low grade tumors and the complications resulting from treatments that affect the patient's quality of life. Our review aimed to critically analyze the current recommendations for PSA testing, based on new data provided by the re-evaluation of the ongoing studies and the updated USPSTF recommendation statement, and to propose a more rational and selective use of PSA compared with baseline values obtained at an approximate age of 40 to 50 years.

The current state of prostate-specific antigen testing.

Since prostate-specific antigen (PSA) testing was approved in 1994, the incidence of metastasis and mortality from prostate cancer have significantly decreased. However, PSA screening for prostate cancer has limitations and few large randomized controlled trials have been conducted to determine the mortality benefit of PSA screening. Two studies that have been conducted are the Prostate, Lung, Colorectal, and Ovarian (PLCO) screening trial and the European Randomized Study of Screening for Prostate Cancer (ERSPC). These were the two main studies the US Preventive Services Task Force (USPSTF) used in its recommendation against prostate cancer screening in 2012. However, new evidence has demonstrated that the PLCO trial had significant limitations and the results of the ERSPC trial were more significant than previously thought. This article describes the strengths and weaknesses of the USPSTF's recommendation, along with current guidelines for prostate cancer screening.

Contemporary National Trends of Prostate Cancer Screening Among Privately Insured Men in the United States

To assess the possible impact of changes to the clinical guidelines from the US Preventive Services Task Force recommendations in 2012 on the national trends of prostate-specific antigen (PSA) screening and identify patient characteristics associated with PSA screening from a large private insurance database. We conducted a retrospective cohort study of men between 40 and 80 years of age who underwent PSA screening for prostate cancer from 2008 to 2013 in a population-based cohort of privately insured patients. Unadjusted and adjusted rates were calculated using member-years and reported per 1000 member-years. Rates of PSA screening remained stable from 190.4 per 1000 member-years in 2008 to 196.4 in 2013 (P = .66). From 2008 to 2013, PSA screening did not change for patients aged 50-59 (236.5 to 241.1 per 1000 member-years; P = .78), 60-64 (284.1 to 288.3 per 1000 member-years; P = .77), 65-69 (250.6 to 248.0 per 1000 member-years; P = .56), and 70-74 (266.4 to 280.3 per 1000 member-years; P = .17). However, patients ≥75 years had marked decrease in the rate of PSA screening from 201.5 to 124.1 per 1000 member-years (P = .04). Across different racial groups, PSA screening rates remain unchanged over time irrespective of age. Among this population-based cohort of privately insured men, we found little effect on PSA screening from changes to the US Preventive Services Task Force clinical practice guidelines. However, the rates of PSA screening were much lower among older men (>75 years). Further research is needed to assess the impact of the new guidelines on prostate cancer incidence and survival.

Utility of Prostate Cancer Screening in Kidney Transplant Candidates.

Screening recommendations for prostate cancer remain controversial, and no specific guidelines exist for screening in renal transplant candidates. To examine whether the use of prostate-specific antigen (PSA)-based screening in patients with ESRD affects time to transplantation and transplant outcomes, we retrospectively analyzed 3782 male patients ≥18 years of age undergoing primary renal transplant evaluation during a 10-year period. Patients were grouped by age per American Urological Association screening guidelines: group 1, patients <55 years; group 2, patients 55-69 years; and group 3, patients >69 years. A positive screening test result was defined as a PSA level >4 ng/ml. We used univariate analysis and Cox proportional hazards models to identify the independent effect of screening on transplant waiting times, patient survival, and graft survival. Screening was performed in 63.6% of candidates, and 1198 candidates (31.7%) received kidney transplants. PSA screening was not associated with improved patient survival after transplantation (P=0.24). However, it did increase the time to listing and transplantation for candidates in groups 1 and 2 who had a positive screening result (P<0.05). Furthermore, compared with candidates who were not screened, PSA-screened candidates had a reduced likelihood of receiving a transplant regardless of the screening outcome (P<0.001). These data strongly suggest that PSA screening for prostate cancer may be more harmful than protective in renal transplant candidates because it does not appear to confer a survival benefit to these candidates and may delay listing and decrease transplantation rates.

PSA Screening for Prostate Cancer: Why Saying No is a High-Value Health Care Choice.

Enthusiasm for cancer screening and treatment of screen-detected cancer has led to widespread prostate-specific antigen (PSA) screening, a marked increase in prostate cancer incidence, and high use of surgical, radiation, and androgen deprivation treatment for screen-detected disease. This has occurred in advance of a full understanding of the clinical and financial tradeoffs. Although questions remain whether lifetime benefits outweigh harms and costs, data indicate that this balance is not favorable through at least 15 years. This article outlines a conceptual framework for determining the value of screening strategies according to screening and treatment intensity. We describe 4 main cancer screening goals and examine whether PSA screening and treatment achieve these goals and thus provide high-value care. Available evidence demonstrates that PSA screening provides at best a small reduction in prostate cancer mortality, and no reduction in all-cause mortality. High-intensity PSA screening and treatment currently practiced in the United States result in substantial harms and large health care expenditures-it is low-value care. The health importance of prostate cancer and the financial costs to patients and society require improved detection and treatment strategies that produce greater value to patients. We propose lower-intensity, higher-value options. However, until evidence supports a higher-value alternative to current PSA screening strategies, physicians should recommend against PSA screening, policymakers should encourage reduced screening, and most men should say no to the PSA test.

PSA Screening for Prostate Cancer Declined from 2007 to 2013

The U.S. Preventive Services Task Force recommended against prostate cancer screening with prostate specific antigen (PSA) in men 75 years and older in

The Ethical Dilemma Surrounding Prostate Specific Antigen (PSA) Screening

The Food and Drug Administration approved testing for prostate cancer screening in 1994. Today over four decades have passed since the Prostate-Specific Antigen (PSA) was first discovered. Yet enormous uncertainty governs the effectiveness of PSA testing as well as the appropriate strategy to best detect early prostate cancer. Many groups including the American Cancer Society (ACS), the National Comprehensive Cancer Network (NCCN), the American Urological Association (AUA) and the US Preventative Services Task Force (USPSTF), have issued a series of clinical guidelines for prostate cancer screening with inconsistent recommendations. Research shows that prostate cancer screening with PSA resulting in a false-positive screen occurs among 80 percent of men, while 20 percent of men have false-negative results. Recently changes to existing recommendations were suggested by the USPSTF due to concerns of negative effects of PSA testing on patient outcomes. While the evidence underlying prostate cancer screening recommendations is continuously in flux, it is important to understand implications of the debate for clinicians and men. In this paper we examine ensuing ethical considerations of PSA screening for prostate cancer.

Inflammation of Prostate and Prostate-Specific Antigen

Noncancerous conditions (e.g., benign prostatic hyperplasia and prostatitis) can elevate serum prostate-specific antigen (PSA) levels, limiting the specificity of PSA screening for prostate cancer. In recent years, several studies have also demonstrated a relationship between chronic prostatitis/chronic pelvic pain syndrome and increased PSA levels. However, in asymptomatic patients, routine screening for this diagnosis is not performed before transrectal biopsy to rule out prostate cancer. These asymptomatic men with elevated PSA levels frequently show evidence of inflammation when their expressed prostatic secretions are examined, or on their prostate biopsy specimens. This raises the problem of appropriate evaluation in the presence of chronic prostatitis and elevated PSA levels not only in prostate cancer screening programs, but also in cancer-negative biopsy findings. Thus, there has been investigation into ways to decrease the confounding from inflammation, including repeat PSA measurements after a period of observation or a course of empiric antibiotics. This article reviews the evidence regarding elevations in PSA due to prostatitis and describes the controversy over the optimal approach to reduce its confounding impact on prostate cancer screening. Nowadays, it appears that in patients with prostatic inflammation and increased PSA, an antimicrobial regimen may provide more acceptable initial treatment than proceeding directly to prostate biopsy. Additional evidence is necessary in the form of a randomized clinical trial in which all patients undergo biopsy, regardless of the PSA response to antibiotic or placebo.

PSA screening for prostate cancer: why so much controversy?

Since prostate cancer reaches the advanced and non curable stage in the absence of any specific symptom or sign, it seems reasonable to diagnose this cancer at an early and curable stage. Screening by prostate-specific antigen (PSA) has been the common technology used. The last follow-up of the first two prospective and randomized screening studies for prostate cancer, namely the Quebec and ERSPC (European Randomized Study of Screening for Prostate Cancer) clinical trials started in 1988 and 1991, respectively, have shown reductions of prostate cancer death of 62% (P<0.002) and 21% (P<0.001) (38% in the tenth and eleventh years of follow-up, P<0.003), respectively, while the PLCO (Prostate Lung Colorectal and Ovarian Cancer) screening trial reported no benefit. It has been estimated, however, that 85% of men in the planned 'non-screened' group of the US study have been screened. With such a serious flaw, the PLCO study does not have the statistical power to reach any valid conclusion. In the Quebec study, only 7.3% of men were screened in the control arm. The important benefit observed in the ERSPC study was achieved using a less than optimal 4-year PSA screening interval which misses a significant number of cancers while the Quebec study used the optimal 1-year interval. With proper information obtained from their physicians or otherwise using data collected only from the clinical trials having the required statistical power, men should be in a good position to decide about being or not being screened for prostate cancer.

Response to the U.S. Preventative Services Task Force Decision on Prostate Cancer Screening

The population-level data demonstrate that the inception of prostate-specific antigen (PSA) screening has lowered mortality for prostate cancer over the past 2 decades. However, more recent evidence from randomized trials has presented conflicting results regarding the benefit of PSA screening for prostate cancer mortality. Using available data, the U.S. Preventative Services Task Force recently recommended against PSA screening for prostate cancer. However, prostate cancer continues to kill over 30,000 men annually, and as such, completely abandoning screening for this disease is a disservice to many patients. Rather, the emphasis should be on utilizing evidence-based medicine to reduce overdiagnosis and overtreatment through less frequent screening for low-risk individuals or those unlikely to benefit from screening, halting further screening when appropriate, and utilizing observational strategies in patients unlikely to suffer clinically significant effects of prostate cancer over their anticipated life expectancy.

Counterpoint

The US Preventive Services Task Force recommended against prostate-specific antigen (PSA) screening for prostate cancer based primarily on 2 large long-term randomized-controlled trials (RCTs) and a systematic review of harms resulting from screening. To support use of large, long-term randomized trials as the evidence base for clinical guidelines on screening and to draw attention to limitations of modeling studies used for this purpose. We respond to critiques of use of RCTs as the primary evidence base, considering the results of the Prostate, Lung, Colorectal and Ovarian (PLCO) and European Randomized Study of Screening for Prostate Cancer (ERSPC) trials, documented harms resulting from PSA screening, and methodological concerns with modeling studies. The PLCO and ERSPC provided 11-13 years of follow-up on over 250,000 subjects. The PLCO, despite limitations, is most representative of US populations, screening and treatment practices, and showed no mortality benefit resulting from annual PSA testing after 13 years of follow-up. The confidence interval was narrow and precluded more than a 13% relative mortality reduction. Competing causes of mortality in older men make it progressively less likely that longer follow-up will demonstrate a large absolute reduction in disease-specific mortality. With continued screening, the increasing prevalence of asymptomatic cancers in older men will increase the rate of overdiagnosis. Potential harms from screening and treatment are significant. Projections from models are subject to mistaken assumptions and investigator biases, and should not be accorded the same weight as evidence from RCTs. Current empiric evidence is sufficient to support the US Preventive Services Task Force guideline that clinicians should recommend against PSA screening for prostate cancer.