AMSTERDAM—French researchers reporting here at the European Cancer Congress concluded that screening for prostate cancer with the prostate-specific antigen (PSA) test does more harm than good (Abstract 1481, accessible via http://eccamsterdam2013.ecco-org.eu/Scientific-Programme/Abstract-search.aspx#).
Professor Mathieu Boniol, PhD, Research Director of the International Prevention Research Institute based in Lyon, noted that even though the United States Preventive Service Task Force has recommended that the PSA test should not be used routinely in asymptomatic men, it has continued to be extremely popular in France, resulting in large numbers of men having radical prostatectomies. More than half of all French men between the ages of 50 and 60 undergo annual PSA screening, he said.
“Even if we take the best scenario—the best hypothesis—about reduction of prostate cancer mortality, the current use of PSA tests in some countries—as in France, for example, where it's used on a large population—does more harm than good.”
For the study, he and his co-researchers attempted to balance the side effects and mortality associated with PSA testing against the benefits. They analyzed data from the European Randomized Study of Screening for Prostate Cancer (ERSPC) to find how many men needed to have had prostate biopsy to detect each case of prostate cancer and compared this with published data on the side effects of biopsy and of surgery.
Boniol also presented results at the Congress from a second study, assessing the use of radical prostatectomy in men age 40 and over in France between 2007 and 2011 using the French Technical Agency for Information on Hospitalization (ATIH) database among 637 hospitals. The risk of death 60 days after the surgery was found to be 0.11 percent overall and after the age of 70, radical prostatectomy was associated with a tripling of 60-day mortality.
He explained that the calculation of “the number of individuals needed to harm” associated with PSA was achieved by applying data from the ERSPC study to a “virtual population” of 1,000 men age 55 to 69 screened using the PSA test and an additional 1,000 men not receiving the test. The published data on mortality and side effects were then applied to the men being tested, and the algorithm was designed to detect any down side of over-diagnosis of prostate cancer, and consequent overtreatment.
Death rates due to prostate cancer were similar in both groups: 5.17 deaths due to prostate cancer were estimated to occur in the group of unscreened men compared with 4.1 deaths in the group who had PSA screening: “The results were clear,” Boniol said: “In order to prevent one death from prostate cancer in the 1,000 men screened for PSA, the number of biopsies would double: with 154 additional prostate biopsies, and—of 35 additional prostate cancers diagnosed—12 additional cases of impotence and three additional cases of incontinence would occur.”
Overall, the prevention of a single death from prostate cancer is associated with a significant “additional adverse-effect burden” from the biopsy and the treatment of prostate cancer, he concluded.
Asked for his opinion, Jack Cuzick, PhD, Professor of Epidemiology at the Wolfson Institute of Preventive Medicine in London, who presented another study on the topic, titled “Should All Men Receive PSA Screening?,” said that until it is possible to clearly separate low-risk cancers—i.e., those that can be safely watched—from the more aggressive ones, population-based screening should not be recommended.
Boniol said that nevertheless, PSA testing does still have a role to play: “We believe that PSA testing should be used as an additional aid in the diagnosis and management of prostate cancer rather than as the major entry point for prostate biopsy and further examinations.”