Controversy Persists About Prostate Cancer Screening

In 2009, the publication of the results of two large screening studies ignited the controversy over prostate-specific antigen (PSA) testing and prostate cancer screening. Now, both studies have been updated and debate continues.

This month, the New England Journal of Medicine published an update of the European Randomized Study of Screening for Prostate Cancer (ERSPC) with two additional years of follow-up. The study reported a 21 percent reduction in prostate cancer morality for participants screened with PSA testing. In the 10th and 11th year of follow-up, the mortality reduction in the screened cohort improved to 38 percent.

On the other hand, an update from the National Cancer Institute’s original report of the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial now with follow up of 13 years continued to find no difference in prostate cancer mortality in study participants who were screened.

So we have conflicting recommendations from the two largest prostate cancer screening trials. While the debate about the overall benefit of screenings may continue, we can still draw helpful conclusions from these two trial updates.

First, it appears that patients can derive the potential benefits from PSA testing by getting screened every two years rather than annually. Second, it takes at least 10 years of follow-up to show the potential benefits of screening. This means that screening will probably not help older men with other significant medical issues. In fact, PSA testing may even cause significant harm from prostate biopsy complications and overtreatment of prostate cancer.
Still, given that the overwhelming majority of patients believe that cancer screening is important to good health, PSA testing is unlikely to diminish. Therefore, physicians should try to reduce the burden of overtreatment by increasing active surveillance in men with low-risk prostate cancer. Future research may help develop genetic testing to identify high-risk patients in order to refine screening targeted to them.

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