One-off PSA screening for prostate cancer does not save lives

Micrograph showing prostatic acinar adenocarcinoma (the most common form of prostate cancer) 

Inviting men with no symptoms to a one-off PSA test for prostate cancer does not save lives according to results from the largest ever prostate cancer trial conducted over 10 years by Cancer Research UK-funded scientists and published today (Tuesday) in the Journal of the American Medical Association (JAMA).
Researchers at the Universities of Bristol and Oxford found that testing asymptomatic men with PSA detects some disease that would be unlikely to cause any harm but also misses some aggressive and lethal prostate cancers.

08 mar 2018--This highlights the flaws of a single PSA test as a way to screen for prostate cancer, and shows the need to find more accurate ways to diagnose cancers that need to be treated.
The CAP Trial, which spanned almost 600 GP practices in the UK and included more than 400,000 men aged 50-69, is the largest trial ever to investigate prostate cancer screening. The trial compared 189,386 men who were invited to have a one-off PSA test with 219,439 men who were not invited for screening.
After an average of 10 years follow up, there were 8,054 (4.3%) prostate cancers in the screened group and 7,853 (3.6%) cases in the control group. Crucially, both groups had the same percentage of men dying from prostate cancer (0.29%).
There is no national screening programme for prostate cancer in the UK, but men over 50 can ask their GP for a PSA test.
More than 11,000 men die of prostate cancer each year in the UK. While some prostate cancers are aggressive and lethal, others are clinically insignificant and will never lead to any harm or death if left undetected. Ideally, aggressive prostate cancers need to be identified and treated as early as possible. But finding a cancer that would never have caused men harm during their lifetime can have a serious impact on quality of life, including the worry of a cancer diagnosis, the possibility of infection following a biopsy and impotence and incontinence following treatment.
Professor Richard Martin, lead author and Cancer Research UK scientist at the University of Bristol, said: "Our large study has shed light on a highly debated issue. We found that offering a single PSA test to men with no symptoms of prostate cancer does not save lives after an average follow-up of 10 years.
"The results highlight the multitude of issues the PSA test raises - causing unnecessary anxiety and treatment by diagnosing prostate cancer in men who would never have been affected by it and failing to detect dangerous prostate cancers. Cancer Research UK is funding work that will allow us to follow the men for at least a further five years to see whether there is any longer-term benefit on reducing prostate cancer deaths."
Dr Emma Turner, a Cancer Research UK scientist at the University of Bristol and co-author of the study, said: "Prostate cancer is the second most common cause of cancer death in men in the UK. We now need to find better ways of diagnosing aggressive prostate cancers that need to be treated early."
Dr Richard Roope, Cancer Research UK's GP expert, said: "The PSA test is a blunt tool missing the subtleties of the disease and causing men harm.
"This trial illustrates that we need to develop more accurate tools if we want to save men's lives. Cancer Research UK's hunt for finding early stages of aggressive prostate cancer is not over. For example, we're funding research into faulty genes which make some men more likely to develop prostate cancer and studying how these genes could help doctors to identify patients who are more at risk.
"We do not recommend that the PSA test should be routinely offered to men without symptoms. However, if a man is particularly worried about his risk of prostate cancer, he should have a full discussion about his risk with his GP."
The UK National Screening Committee does not recommend PSA screening for prostate cancer, but men over the age of 50 without symptoms can ask to be tested as per the Prostate Cancer Risk Management Programme (PCRMP).
Cancer Research UK is calling for Public Health England's PCRMP to be updated to reflect the evidence from the CAP trial.
Each year there are about 47,000 cases of prostate cancer and more than 11,000 deaths in the UK and about 165,000 cases and 29,000 deaths in the US.

More information: Journal of the American Medical Association (2018). DOI: 10.1001/jama.2018.0154


Provided by Cancer Research UK

Impact of 2012 USPSTF guideline against PSA screening explored

05 jan 2016—Patients undergoing prostate needle biopsies after the 2012 U.S. Preventive Services Task Force (USPSTF) recommendation against prostate-specific antigen-based screening for prostate cancer for men of any age are more likely to be diagnosed with high-risk disease, according to research published in the January issue of The Journal of Urology.

John S. Banerji, M.D., from the Virginia Mason Medical Center in Seattle, and colleagues reviewed data from a prospective database of patients undergoing prostate needle biopsies from 2004 to 2014. The authors compared patients seen before and after the USPSTF recommendations.
The researchers found that, compared with the 1,416 patients in the pre-USPSTF group, the 310 patients in the post-USPSTF group had a higher prostate-specific antigen (P < 0.001); they were also more likely to be diagnosed with higher clinical stage (2b, P = 0.003; 2c-3a, P = 0.027) and D'Amico high-risk prostate cancer (P = 0.036), with an adjusted relative risk of 1.25 for high-risk prostate cancer. Similar results were seen when the pre-USPSTF group was limited to 448patients seen in the 30 months before the draft guidelines. There was a 31 percent decrease in the absolute number of biopsies performed, with most of the decrease occurring in the detection of intermediate-risk tumors.
"Future focus on informed application of screening techniques may prevent the reversal of decades of improvement in the prostate cancer mortality rate," the authors write.

More information: Abstract

Full Text

Researchers find many elderly men are undergoing unnecessary PSA screenings

A new study on the use of prostate-specific antigen (PSA)-based prostate cancer screening in the United States found that many elderly men may be undergoing unnecessary prostate cancer screenings. Using data from surveys conducted in 2000 and 2005, researchers report that nearly half of men in their seventies underwent PSA screening in the past year – almost double the screening rate of men in their early fifties, who are more likely to benefit from early prostate cancer diagnosis and treatment. Further, men aged 85 and older were screened just as often as men in their early fifties.

30 mar 2011--Because prostate cancer tends to be slow-growing, data show that many men – particularly those in their seventies and older – will die of other causes before prostate cancer becomes a problem that requires medical attention. The new findings underscore a long-standing concern that overuse of PSA screening and PSA-based treatment decisions may lead to unnecessary treatment of many older men and potential complications such as incontinence, impotence and bowel dysfunction.

"Our findings show a high rate of elderly and sometimes ill men being inappropriately screened for prostate cancer. We're concerned these screenings may prompt cancer treatment among elderly men who ultimately have a very low likelihood of benefitting the patient and paradoxically can cause more harm than good," said senior author Scott Eggener, MD, assistant professor of surgery at the University of Chicago. "We were also surprised to find that nearly three-quarters of men in their fifties were not screened within the past year. These results emphasize the need for greater physician interaction and conversations about the merits and limitations of prostate cancer screening for men of all ages."

While large declines in prostate cancer metastases and death rates in the last 20 years coincide with widespread use of PSA-based screening, questions remain about its use. Data have been unclear about when men should be considered for PSA screening and when screening should stop, and recent studies have provided conflicting evidence on whether routine PSA screening in the general population of men actually reduces the risk of dying from prostate cancer. Based on these concerns, major organizations such as the American Cancer Society now encourage men who expect to live at least 10 years to talk with their doctor about the risks and benefits of screening, starting at age 50 for men with an average risk or at age 45 for men with a higher risk.

In this study, the researchers examined results from health surveys of randomly selected households conducted in 2000 and 2005 as part of the federal government-sponsored National Health Interview Survey. In addition to reviewing survey data, which included information on age, smoking, mass-body index, underlying medical conditions and other factors, the investigators calculated the estimated five-year life expectancy of each man over 40 who had received a PSA test.

They divided survey results of men age 70 and older into five-year age groups (70 to 74, 75 to 79, 80 to 84, and 85 years and older). In all, 2,623 men ages 70 and older were included in the analysis, while nearly 12,000 men between the ages of 40 and 69 served as controls.

The overall PSA screening rate within the past year for men aged 40 and older was 23.7 percent in 2000 and 26.0 percent in 2005. The PSA screening rate was lowest in the 40 to 44 age group (7.5 percent). Researchers found that the PSA screening rate was 24.0 percent in men ages 50 to 54, increasing with age until a peak of 45.5 percent in ages 70 to 74. Screening rates then declined with age, with 24.6 percent of men 85 or older reporting being screened.

Among men who were 70 or older, the investigators did find that PSA screening was more common in men with a greater estimated five-year life expectancy. For example, approximately 47.3 percent of men who were unlikely to die in five years (an estimated chance of 15 percent or less) were screened, 39.2 percent of men with an intermediate chance (16 to 48 percent probability) of dying received screening, and 30.7 percent of those with the highest probability of death (48 percent or greater) in five years were screened.

Eggener offered some possible explanations for the results, noting that screening rates may reflect how frequently men visit primary care physicians. Older men tend to have more health problems that require doctor visits, and this may in turn result in more frequent PSA testing than younger men, who see their doctors less. The authors suggest that physicians should be more selective in recommending PSA testing for older men, particularly those with a limited life expectancy, and consider more routinely screening younger, healthier men who are most likely to benefit from early prostate cancer diagnosis and related treatment. Men are encouraged to talk with their doctor about their individual risk for prostate cancer, and about the risks and benefits of prostate cancer screening.

More information: http://www.cancer. … state+Cancer

Provided by American Society of Clinical Oncology