Prostate Cancer Screening (PDQ®): Screening - Health Professional Information [NCI] - Evidence of Benefit
Summary of First Four Prostate, Lung, Colorectal, and Ovarian Screening Roundsa continued...
While the ERSPC demonstrated a 29% relative reduction in mortality from prostate cancer among men who were screened at 4-year intervals, there were associated harms from overdiagnosis and long-term treatment effects. Microsimulation Screening Analysis (MISCAN) was used to estimate the quality-adjusted life-years (QALYs) associated with annual PSA screening, based on results from the ERSPC trial. Health states considered in the analysis of QALYs included biopsy, cancer diagnosis, radiation therapy, radical prostatectomy, active surveillance, postrecovery period, palliative therapy and terminal illness. Adverse effects considered included overdiagnosis and various degrees of incontinence and erectile dysfunction. The model predicted that annual screening of 1,000 men aged 55 to 69 years would lead to nine fewer deaths from prostate cancer (98 men screened to prevent one prostate cancer death). Overall, 73 life-years would be gained, but QALYs gained was only 56 life-years on average with a range of -21 to 97 life-years. Screening men aged 55 to 74 years increased life-years gained but resulted in the same number of QALYs on average (56 life-years).
The Finnish Randomized Screening Trial is the largest component of the multicenter ERSPC consortium. Eighty thousand one hundred forty-four men born between 1929 and 1944 were identified from the Finnish Population Registry. Men with a previous prostate cancer diagnosis were excluded. Thirty one thousand eight hundred sixty-six men were randomly assigned to the screening arm (SA) and the remaining 48,278 men were randomly assigned to the control arm (CA). Randomization occurred annually from 1996 to 1999 (at ages 55, 59, 63, or 67 years at entry, which led to a similar age distribution in both arms). Men randomly assigned to the CA were not contacted. Men randomly assigned to the SA were invited to an initial screen, and if living in the study area and not already diagnosed with prostate cancer, were invited to second and third screenings at 4 and 8 years after randomization. Men with a PSA of 4.0 ng/mL or higher were referred to a local urological clinic for diagnosis. Men with a PSA of 3.0 to 3.99 ng/mL were referred to further testing. Median follow-up in both arms was 10.8 years. The screening arm had a nonstatistically significant reduction in prostate cancer mortality, based on an analysis of those who were invited to be screened. The hazard ratio between trial arms was 0.85 (95% CI, 0.69-1.04; P = .10). No screening effect was seen in all-cause mortality. Treatment differed between the two arms within each risk category. In all risk categories, radical prostatectomy was more common in the SA (statistically significant at P < .05 for moderate- and high-risk cancers) and radiation and endocrine treatment were more common in the CA (statistically significant at P < .05 for radiation in the moderate-risk category and for both radiation and endocrine treatment in the high-risk category). It was unknown whether this affected mortality. Contamination in the CA was not measured.