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Focused Screening Strategy for Prostate Cancer

Summary and Comment |
May 1, 2014

Focused Screening Strategy for Prostate Cancer

  1. Paul S. Mueller, MD, MPH, FACP

Men whose prostate-specific antigen levels at age 60 are ≥2 ng/mL might benefit most from screening.

  1. Paul S. Mueller, MD, MPH, FACP

Although screening men for elevations in serum prostate-specific antigen (PSA) levels might lower prostate cancer–specific mortality (NEJM JW Gen Med Mar 18 2009), widespread screening is costly and results in substantial overtreatment. For each prostate cancer death prevented during 11 years of follow-up in a recent European study, about 1000 men were screened, and >30 prostate cancers were diagnosed (NEJM JW Gen Med Mar 14 2012). Might a focused approach be more effective? In this study, investigators in Sweden assessed how baseline serum PSA levels at age 60 modified the effects of screening.

The screened group consisted of 1800 men who participated in the screening arm of the Gothenburg randomized prostate cancer screening trial; the unscreened group consisted of 1200 men who participated in the Malmö Preventive Project (in whom PSA levels were measured retrospectively using stored blood samples). The distributions of PSA levels at age 60 were similar between the groups and were <2 ng/mL in 72% of participants.

After 15 years follow-up, risks for prostate cancer diagnosis, metastasis, and death increased with higher baseline PSA levels. For 60-year-old men with PSA levels <2 ng/mL, screening yielded no benefit. However, for those with PSA levels ≥2 ng/mL, screening significantly lowered prostate cancer–specific mortality; for each prostate cancer death prevented during 15 years of follow-up, only 23 men would be screened, and 6 prostate cancers would be diagnosed.

Comment

The results of this study suggest that, rather than widespread annual prostate-specific antigen screening, we should focus on high-risk men (those with PSA levels ≥2 ng/mL at age 60). Such a strategy would lower prostate cancer–specific mortality and result in less testing. Low-risk men (i.e., those with PSA levels <2 ng/mL at age 60 — nearly three quarters of the men in this study) could be exempted from subsequent screening. These results should be confirmed by randomized trials.

  • Disclosures for Paul S. Mueller, MD, MPH, FACP at time of publication Consultant / advisory board Boston Scientific (Patient Safety Advisory Board) Leadership positions in professional societies American Osler Society (Secretary)

Citation(s):

Reader Comments (1)

Dr. V Kantariya MD Physician, Family Medicine/General Practice

There is no level of PSA that is diagnostic, PSA is an
indicator of prostate drowth, BPH tissue produces one tenth as much PSA per gram as cancer tissue does. PSA Density at cut-off value 0.15 has been used to decrease the number of prostate biopsy. What is the role Age-Obesity-PSA Relationship (Hekallis Equation)?

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