COMMENTARY

Prostate Cancer Screening: It Ain't Dead Yet

Charles P. Vega, MD

Disclosures

May 27, 2014

In This Article

Prostate Cancer

Prostate cancer is the second leading cancer killer in the United States, yet 2 large randomized trials of screening for prostate cancer provided mixed, and generally unfavorable, results.[1,2] New research continues to underscore the dichotomy between the results of screening programs in Europe and the United States. However, new and highly interesting data also suggest that infrequent screening with prostate-specific antigen (PSA) levels may help to reduce the overdiagnosis of prostate cancer. This review examines the state of the art in prostate cancer screening.

Screening for Prostate Cancer

There are few areas more controversial in clinical medicine than screening for prostate cancer. The high prevalence of prostate cancer, especially in light of an increasingly older male population, and its impact on personal and public health, cannot be denied. In 2012, more than 240,000 new cases of prostate cancer were diagnosed in the United States, and prostate cancer accounted for 28,170 deaths.[3]Prostate cancer is the number-two cancer killer among US men, trailing only lung cancer. Overall, the lifetime risk for prostate cancer among men in the United States is 16.5%.

Nonetheless, the tools promoted to screen men for asymptomatic prostate cancer are clearly flawed. In its 2012 recommendation against routine screening for prostate cancer, the US Preventive Services Task Force cites 2 major trials in influencing its decision.[4]

Results from the Prostate, Lung, Colon, and Ovarian (PLCO) Cancer Screening Trial in the United States failed to detect any benefit associated with prostate cancer screening in preventing prostate cancer-specific mortality after 7-10 years.[1] In the European Randomized Study of Screening for Prostate Cancer (ERSPC), 162,000 men between the ages of 55 and 69 years underwent randomization to PSA screening at an average of once every 4 years, or no screening.[2] Screening was associated with an overall reduction in the risk for death from prostate cancer of 20% -- a significant result but modest, considering that 1410 men would have to be invited to screening to prevent 1 additional death from prostate cancer.

This recommendation and other articles highlighting the limitations of PSA screening have led to a profound change in clinical practice. In a study evaluating PSA screening performed in multiple centers between 2008 and 2012, PSA testing increased until March 2009, when the PLCO and ERSPC trial results were published.[5] Afterward, there was a steady decline overall in the number of screening PSA tests ordered, with the most substantial reductions occurring in urology practices and among men aged 50-59 years.

But are we being too hasty in dismissing prostate cancer screening as ineffective and wasteful? New research on the large cohorts randomly assigned to screening vs usual care in the European trial suggest that the relative value of earlier prostate cancer detection may increase as men grow older. Other studies suggest smarter, more efficient ways to use PSA to identify men at high risk for prostate cancer.

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