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Alternative screening methods may reduce mortality in prostate cancer
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Prostate cancer screening methods that raise the threshold for biopsy referral for older men and reduce screening among those with low PSA may reduce mortality, according to recent findings.
The aim of the current microsimulation model of prostate cancer incidence and mortality was to compare efficacy of alternative PSA screening strategies.
Investigators analyzed US national and trial data on PSA usage, patterns and mortality.
The analysis included 35 screening strategies that varied by age, interval and thresholds for referral to biopsy.
Outcomes included PSA tests, false-positive results, cancers detected, overdiagnoses, prostate cancer deaths, lives saved and months of life saved.
A prostate cancer mortality risk of 2.86% occurs without screening. A strategy for annual screening of men aged 50 to 74 years and a biopsy referral of 4 mcg/L was associated with a reduction in prostate cancer mortality of 2.15%. This strategy carried an overdiagnosis risk of 3.3%.
A strategy that employs a higher PSA threshold for referral in older patients was associated with a mortality risk of 2.23%. However, this strategy reduced overdiagnosis risk to 2.3%.
Biennial screening with longer intervals for men with low PSA was linked to a mortality risk of 2.27% and an overdiagnosis rate of 2.4%. This strategy was associated with a 59% reduction in total tests and a 50% reduction in false-positive results.
“Compared with standard screening, PSA screening strategies that use higher thresholds for biopsy referral for older men and that screen men with low PSA levels less frequently can reduce harms while preserving lives,” the researchers concluded.
Perspective
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Jay P. Ciezki, MD
This evaluation of PSA-based prostate cancer screening strategies is interesting because of its sensitivity to the fact that there are several ways to employ PSA screening. The authors focus on changing the PSA threshold for biopsy and the frequency of screenings. They conclude that alternate screening strategies may reduce harm while preserving lives.
In stating their conclusion, the authors make the same mistake that most others in this field have made. They ignore the natural history of prostate cancer and, in doing so, divorce their work from clinical applicability.
The use of prostate cancer–specific survival as a main outcome does not help one evaluate the effect of PSA screening on the most costly endpoint in terms of quality of life and money: metastatic disease burden of the screened population. Several other sources provide evidence that the metastatic burden of the screened population is significantly reduced by screening and subsequent treatment with a minimal effect on survival (Wilt TJ. N Engl J Med. 2012;367:203-213; Loeb S. BJU Int. 2012;110:1678-1683).
With the cost of some newer drugs exceeding $90,000 per treatment course and the multiple hospitalizations for palliation of metastatic disease, it is inexcusable to not report on this important endpoint.
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