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PSA - the verdict is in

by Michael Woodhead  

PSA screening does not reduce prostate cancer mortality – or maybe it does.  

These are the long-awaited answers from two major prospective studies of PSA screening for prostate cancer carried out in Europe and the US.  

Published today in the NEJM (online 18 March), the US findings from almost 77,000 men found no benefit of prostate cancer screening after up to ten years of follow up in men offered PSA testing and digital rectal examination.  

However the study authors said benefits of screening may have been masked by recent improvements in prostate cancer treatment, or may be more evident after longer follow up.  

A larger European study that followed up 162,000 men in the 55-69 age group found a 20% relative reduction in prostate cancer mortality in men offered PSA screening. This meant that 1410 men would need to be screened and 48 additional more men treated to prevent one death, the study authors said.  

However, they said screening was associated with a high rate of overdiagnosis.  

The bottom line, according to an accompanying editorial, is that serial PSA screening has at best a modest effect on prostate cancer mortality during the first decade of follow up. And the benefit comes at the cost of substantial overdiagnosis and overtreatment.  

It concludes that like beauty, the perceived value of prostate cancer screening is likely to be in the eye of the beholder.  

“Some well-informed clinicians and patients will see [the trade offs] as favourable, others will see them as unfavourable.”  

Therefore the importance of a shared decision-making process between clinician and patient is more relevant than ever, it concludes.


19 March 2009
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Latest Comments

  • I have monitored my own PSA annually from the age of 50 to find it around 3 to 4 and then suddenly 6.8 at the age of 55. This corresponded to a Gleeson 9 tumour which was subjected to a radical prostatectomy. Now 5 years later I have an unmeasurable PSA still. One patient is perhaps not a huge statistical sample but I have no doubt that I would now have widespread disease if not be actually dead were it not for this test and one can't help but be influenced by one's personal experiences. Furthermore I can't actually imagine why this scenario would be an uncommon one as the studies mentioned would imply.

    Posted by Lee Simes, GP, Nowra, NSW 19/03/2009 7:19:45 PM

  • That prostate screening is at best useless and at worst misleading and capable of causing harm to men with no cancer has long been supported by the literature. I resent the zealites who have promoted prostate screening given the knowledge that was already available. No donations from me to the Prostate Foundation.

    Posted by Dr Bob Meehan, Murwillumbah 19/03/2009 9:24:58 PM

  • It is true that there are individual cases in which a patient has benefited from PSA screening. That, however, does not justify screening. Patients who benefit from screening must be balanced against those who are harmed by it.

    PSA testing has poor sensitivity and specificity. Unnecessary prostatectomies are risky; they sometimes have unfavourable outcomes. So can unnecessary prostate biopsies. Additionally, patients who present with symptoms of prostate cancer may have diagnosis delayed because of the false negative of a low PSA reading.

    All these patients have been harmed by the screening and this must be taken into account, along with the other costs of screening, including unnecessary anxiety, theatre time being wasted and possible transfer of infection in hospital as well.

    Posted by Chris Ewing 20/03/2009 4:49:40 PM

  • Dear Dr Bob Meehan of Murwillumbah

    I object to being referred to as a cross between an inorganic filtering material and a synthetic polymer but I am delighted to be considered a "zealot". Perhaps you might like to consider an approach to screening involving younger men to whom you have, at the beginning, explained the need to resist alarm at first PSA rise but to graph it over a period of time. I have had only 2 negative biopsies in five years and 4 positives with high grade tumours under the age of 60 with several other low grades that are being watched. It may not be a perfect test but I am quite sure I have saved some lives with it and I have not seen a complication from biopsy so far. That sort of statistic means that properly used and with proper explanation at the beginning it is far from useless and misleading. I am old enough to remember the days before sophisticated imaging and the PSA test and I can remember signing death certificates "disseminated adenocarcinoma, primary unknown" in younger men. I now have no doubt, where that primary was. I have now watched a friend and colleague (GP) die at the age of 59 of prostatic malignancy. He shared your prejudice until he presented with a spontaneous pathological fracture of the femur.

    Lee Simes GP Nowra NSW

    Posted by Lee Simes 20/03/2009 9:29:58 PM

  • Dear Dr Chris Ewing

    Your response is far too all encompassing to be acceptable. What I am talking about is the need to detect high grade tumours in younger men. Everything you say about a PSA is true but I am not advocating leaping in and biopsying every little glitch in a level at first contact but monitoring it over some months having counselled the patient adequately before you commence the process. Such counselling would also remove your concern about a false sense of security. Furthermore a PSA is cheaper than a PAP smear and very,very much cheaper than a mammogram. Perhaps you might also like to consider the theatre time wasted by negative colonoscopies generated by FOB screening. I am not talking about doing radical prostatectomies in low grade tumours in 80 year olds, I am talking about detecting and early treatment of high grade tumours in men in their 50's. The opponents of the application of this test persistently fail to draw the distinction between what might as well be two different diseases. If you are concerned about nosocomial infection you should take a look at what goes on in orthopaedic wards.

    Lee Simes GP Nowra NSW

    Posted by Lee Simes 21/03/2009 6:32:23 AM

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