ECC 2013: French Study Finds Routine PSA Screening Does More Harm Than Good
There is no consensus on the value of routine prostate-specific antigen (PSA) screening. Weighing in on this issue, investigators presented a study at the European Cancer Congress 2013 in Amsterdam (Abstract 1481) suggesting that population-based PSA screening does more harm than good. The study was based on a model that found that routine PSA screening in 1,000 men aged 59 to 69 would avoid only one prostate cancer–specific death and one high-risk prostate cancer.
“There have been conflicting results from two large randomized trials—one in Europe and one in the United States—on the impact of PSA screening on prostate cancer mortality. Despite a lack of evidence that screening reduces prostate cancer deaths, increasing use of PSA screening has occurred [in France]. This leads to overdiagnosis and overtreatment of low-grade tumors that would cause no harm. We found that PSA screening brings more harm than benefit, and we agree with the [American Urological Association] statement of May 2013 that routine PSA tests should be stopped,” said lead author Matthew Boniol, MD, of Hospices Civils de Lyon in Lyon, France.
Rise in PSA Screening Has Not Reduced Mortality
As background, Dr. Boniol showed some population-based data. In the 1980s, before PSA testing was routinely done, the incidence of prostate cancer was 5% and the rate of prostate cancer–specific death was 2%.
“This shows that less than half of the men who underwent screening would have died of prostate cancer in that time period,” he emphasized.
In 2000, after PSA screening was being used routinely, the incidence of prostate cancer rose to 14% but the risk of prostate cancer-specific death remained at 2%.
“This means that most cancers diagnosed after PSA screening would never have become clinically detectable,” he continued.
Autopsy series show that many men carry clinically silent prostate cancer, and there is a huge reservoir of cancers that lead to only 2% of deaths, he explained.
Study Details
The current study was based on an estimate of the number of individuals needed to harm with PSA testing by applying side-effect estimates to a virtual population of 1,000 men aged 55 to 69 who were exposed to PSA testing and another 1,000 age-matched men who were not exposed to testing. Based on a systematic literature review, the investigators extracted results of PSA testing, biopsy rates, and the impact on prostate cancer–specific death from the European Randomized Study on Screening for Prostate Cancer (ERSPC).
“ERSPC showed that PSA screening reduced mortality by 20%, so we used a best case scenario,” Dr. Boniol told listeners.
In the group of 1,000 unscreened men, it was estimated that 120 biopsies would have been performed, 60 prostate cancers diagnosed, and 5 deaths due to prostate cancer would have occurred.
Using the ERSPC screening protocol, the researchers found that PSA screening in 1,000 men would avoid only one prostate cancer–specific death and one high-risk prostate cancer; 147 additional biopsies would have been conducted to detect 36 additional prostate cancer cases in this group, which would represent overdiagnosis.
Dr. Bonial pointed out that overdiagnosis leads to overtreatment, which in turn exposes patients to harmful side effects of primary treatment with surgery or radiation—impotence, urinary and fecal incontinence, and morbidity associated with the biopsy itself.
Physicians and Patients Should Be Educated on Risks, Benefits of Screening
The study was conducted in France, where 80% of the male population undergoes routine PSA screening, usually ordered by a general practitioner. However, uptake of routine PSA screening is lower in other countries, including the United States and United Kingdom.
Cora Sternberg, MD, Chief of Medical Oncology at the San Camillo and Forlanini Hospitals in Rome and moderator of the press conference where the study was discussed, commented that the results demonstrate what would happen with massive use of PSA screening. PSA screening is still important in men with risk factors, such as family history and African American race. The decision to undergo PSA screening should be based on careful individualized discussions with patients, she noted.
Family physicians should be educated on the risks and benefits of PSA screening, she added.
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
