UroToday – The use of PSA screening for the detection and treatment of prostate cancer (CaP) has been controversial. Two articles on this topic appear in the March 18, 2009 online edition of the New England Journal of Medicine. This article by Professor SchГ¶der and associates and the other by Dr. Andriole and colleagues are both reviewed in Urotoday.

Professor Schöder and co-authors participated in the European Randomized Study of Screening for Prostate Cancer (ERSPC), a randomized, multi-center trial of screening for CaP with cause-specific mortality as the primary endpoint. In general, men between the ages of 55-69 were randomized; 82,816 to the screening group and 99,184 to the control group. A PSA cutoff value of 3.0ng/ml was used as an indication for a prostate biopsy. Over the course of the study, an increasing number of prostate biopsy cores were used. For almost all centers, the screening interval was 4 years. Pathology was not centrally reviewed. The study was designed with a power of 86% to show a statistically significant difference of 25% or more in CaP mortality.

The mean age at randomization was 60.8 years, and 82.2% of men in the screened group were screened once or more. An average of 2.1 PSA tests were performed among screened men and overall 16.2% were positive. Compliance with the recommended biopsy was 85.8%. CaP was detected in 5,990 men in the screened group and 4,307 men in the control group, corresponding to a cumulative incidence of 8.2% and 4.8%, respectively. The positive predictive value of a biopsy was 24.1% and the cumulative incidence of localized CaP was higher in the screened group. With an average follow-up time of 8.8 years, there were 214 and 326 CaP deaths in the screened and control groups, respectively. The rates of death in the two groups began to diverge at year 7 and continued to do so. The number of men who would need to be screened to prevent one CaP death is 1,410. There were no deaths reportedly associated with the prostate biopsy.

Thus, the study reports that PSA screening is associated with a significant absolute reduction of 0.71 CaP deaths per 1,000 men an average follow-up of 8.8 years. This corresponds to a relative reduction of 20% in the rate of CaP death among men between the ages of 55 and 69 years. This study differs from the PLCO trial in that the PSA cutoff was lower at 3.0ng/ml, the study was of longer duration and the screening interval greater at 4 years.

Schröder FH, Hugosson J, Roobol MJ, Tammela TL, Ciatto S, Nelen V, Kwiatkowski M, Lujan M, Lilja H, Zappa M, Denis LJ, Recker F, Berenguer A, Määttänen L, Bangma CH, Aus G, Villers A, Rebillard X, van der Kwast T, Blijenberg BG, Moss SM, de Koning HJ, Auvinen A; ERSPC Investigators.
Collaborators: 156
N Engl J Med. 2009 Mar 26;360(13):1320-8

UroToday Contributing Editor Christopher P. Evans, MD, FACS

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