COMMENTARY

Mortality Risk With Prostate Biopsy Raises Concern

Gerald Chodak, MD

Disclosures

June 17, 2013

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Hello. I'm Dr. Gerald Chodak for Medscape. At the 2013 American Society of Clinical Oncology Annual Meeting, a very provocative paper was presented by Boniol and associates.[1] They analyzed the 120-day mortality rates in men who participated in the PLCO (Prostate, Lung, Colorectal, and Ovarian) screening trial, and the results were somewhat disturbing. They observed that at 120 days, the death rate was 1.3 per 1000 biopsies done in men without cancer, and was higher -- 3.5 per 1000 men -- in those who had a positive biopsy for cancer.

This is somewhat consistent with a previous analysis of the European Randomized Study of Screening for Prostate Cancer.[2] That study resulted in a net conclusion that the harms outweighed the benefits. It's important to understand how this occurs. If someone dies prematurely from a biopsy at an average age of 62, he may have lost about 13 years from his life expectancy. On the other hand, for those men who are avoiding a cancer death as a result of screening, which we know is about 1 per 1000 men screened in 12 years, they may gain only a few years of added life expectancy from the time they would have died of something else.

We know from breast cancer screening that the average increase in life expectancy is only about 2.3 years. We now total up the number of men who die from a biopsy and don't have cancer and the men who die from a biopsy and do have cancer, and we also factor in the number of men who die as a consequence of treatment, which we believe to be about 0.2% of men who undergo a radical prostatectomy. The total average number of years of life expectancy lost, at best, is similar to what you gain from saving lives, but it is probably less than that.

In other words, the net impact is that you lose years of life expectancy in a population that gets tested. Some might argue that you might have a younger group of men who are healthier and they have a lower rate of dying; it's not clear why these deaths occurred. Most of the deaths are likely to be due to infection, but we don't know for sure. The bottom line here is that we can't ignore this complication, and the impact it has on overall life expectancy, when we try to evaluate the net benefits and harms of screening for this disease.

There is no doubt that many people are going to find this added piece of information even more difficult to accept, but the fact is that, in a well-done study with a full analysis of good data, these are the mortality rates that were observed. They further shift the net balance toward harms over benefits from screening for this disease. I look forward to your comments. Thank you.

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