Natural experiment examining impact of aggressive screening and treatment on prostate cancer mortality in two fixed cohorts from Seattle area and Connecticut

doi:10.1136/bmj.325.7367.740

BMJ 2002;325:740 ( 5 October )

Papers

Natural experiment examining impact of aggressive screening and treatment on prostate cancer mortality in two fixed cohorts from Seattle area and Connecticut

Papers p 740 Education and debate p 766

Grace Lu-Yao, director, ^a Peter C Albertsen, professor of surgery, ^b Janet L Stanford, member and head, Program in Prostate Cancer Research, ^c Therese A Stukel, professor of biostatistics, ^d Elizabeth S Walker-Corkery, research coordinator, ^e Michael J Barry, associate professor of medicine, Harvard Medical School. ^e

^a HealthStat, PO Box 7501, Princeton, NJ 08543, USA, ^b Division of Urology, Department of Surgery, University of Connecticut Health Center, MC 3955, Farmington, CT 06030, USA, ^c Division of Public Health Sciences, Programs in Epidemiology and Prostate Cancer Research, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, MW-814, Seattle, WA 98109, USA, ^d Center for the Evaluative Clinical Sciences, Dartmouth Medical School, 7251 Strasenburgh, Hanover, NH 03755, USA, ^e Medical Practices Evaluation Center, Massachusetts General Hospital, 50 Staniford Street, 9th floor, Boston, MA 02114, USA

Correspondence to: M J Barry mbarry{at}partners.org

Objective: To determine whether the more intensive screeningand treatment for prostate cancer in the Seattle-Puget Sound areain 1987-90 led to lower mortality from prostate cancer than inConnecticut.
Design: Natural experiment comparing two fixed cohortsfrom 1987 to1997.
Setting: Seattle-Puget Sound and Connecticut surveillance,epidemiology, and end resultsareas.
Participants: Population based cohorts of male Medicarebeneficiaries aged 65-79 drawn from the Seattle (n=94 900) andConnecticut (n=120 621)areas.
Main outcome measures: Rates of screening for prostate cancer, treatmentwith radical prostatectomy and external beam radiotherapy, andprostate cancer specificmortality.
Results: The prostate specific antigen testing ratein Seattle was 5.39 (95% confidence interval 4.76 to 6.11) timesthat of Connecticut, and the prostate biopsy rate was 2.20 (1.81to 2.68) times that of Connecticut during 1987-90. The 10 yearcumulative incidences of radical prostatectomy and external beamradiotherapy up to 1996 were 2.7% and 3.9% for Seattle cohortmembers compared with 0.5% and 3.1% for Connecticut cohort members.The adjusted rate ratio of prostate cancer mortality up to 1997was 1.03 (0.95 to 1.11) in Seattle compared withConnecticut.
Conclusion: More intensive screening for prostate cancerand treatment with radical prostatectomy and external beam radiotherapyamong Medicare beneficiaries in the Seattle area than in the Connecticutarea was not associated with lower prostate cancer specific mortalityover 11 years of followup.

What is already known on this topic
Screening for prostate cancer with the prostate specific antigen test is widely practised in the United States and has resulted in a remarkable increase in incidence of diagnosed disease

Randomised trials are under way to determine whether early detection and aggressive treatment reduce mortality from prostate cancer

Recent reductions in prostate cancer mortality in the United States have been attributed to screening and treatment, raising questions about whether continuing the trials is ethical

What this study adds
Prostate cancer screening and treatment were much more intensive among men in the Seattle-Puget Sound area than in Connecticut early in the "prostate specific antigen era"

Over 11 years of follow up, no difference in prostate cancer mortality was seen in the two cohorts

The lack of association between more intensive screening and treatment and lower prostate cancer mortality suggests that trials should continue in order to settle this question

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