Prostate cancer screening reduces deaths

BMJ 1998; 316 doi: (Published 30 May 1998) Cite this as: BMJ 1998;316:1625
  1. Fred B Charatan
  1. Florida

    Routine screening for prostate cancer would significantly reduce mortality, according to the first large scale randomised trial.

    Professor Fernand Labrie from Laval University in Quebec presented the trial's results at the annual meeting of the American Society of Clinical Oncology in Los Angeles last week. More than 46000 men aged between 45 and 80 years were randomly allocated to be screened or to receive no screening (standard medical practice). Men were invited by letter for screening.

    At the first visit all the men in the screening group had their prostate specific antigen (PSA) concentrations measured and had a digital rectal examination. A PSA measurement of 3.0 ng/ml was taken as the upper limit of normal. Ultrasonography of the prostate was performed only if the serum PSA result or digital rectal examination was abnormal.

    Deaths from prostate cancer were identified from the province's death register between 1 January 1989 and 31 December 1996. Only five deaths from prostate cancer occurred in the 8137 men who were screened—an incidence of 15.0 cancer deaths per 100000 men years. In the 38056 men who were not screened, 137 deaths occurred— an incidence of 48.7 deaths per 100000 men years.

    This threefold reduction (or 69% decrease) in prostate cancer death in favour of men who were screened was highly significant (P<0.01). Of the five men who died from prostate cancer in the screened group, four had it diagnosed at their first visit, three of whom had metastatic disease.

    Dr Labrie said: “If screening is started, as suggested by the American Cancer Society and by us, at the age of 50 years, diagnosis of metastatic prostate cancer should practically disappear.”

    Dr Labrie concluded: “Our strong recommendation is to start PSA measurements annually at the age of 50 years in the general population, and at 40 years for those at high risk—namely, those with a familial history of prostate cancer and black Americans.” He said that those with serum PSA concentrations below 2.0 ng/ml (70% of the population) could have PSA measured every second year. Men with abnormal PSA (above 3.0 ng/ml) should have further tests, especially digital rectal examination, transrectal ultrasonography of the prostate, and (when appropriate) biopsy. The cost of diagnosing one case of prostate cancer at the first visit has been evaluated at $3000 (£1900), well below the costs of diagnosing one case of breast or cervical cancer.

    However, critics of Professor Labrie's study said that of the more than 30 000 men invited for screening, only 23% accepted.

    Embedded Image

    An enlarged prostate gland with cancer (shown in green)


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