Analysis

Screening for prostate cancer remains controversial

BMJ 2009; 339 doi: http://dx.doi.org/10.1136/bmj.b3601 (Published 24 September 2009) Cite this as: BMJ 2009;339:b3601
  1. Jennifer R Stark, postdoctoral fellow of epidemiology12,
  2. Lorelei Mucci, assistant professor of epidemiology125,
  3. Kenneth J Rothman, professor of epidemiology and medicine34,
  4. Hans-Olov Adami, professor of epidemiology156
  1. 1Department of Epidemiology, Harvard School of Public Health, 677 Huntington Avenue, Boston MA 02115, USA
  2. 2Channing Laboratory, Department of Medicine, Brigham and Women’s Hospital, Harvard Medicine School, Boston MA
  3. 3RTI Health Solutions, Research Triangle Institute, Research Triangle Park, NC
  4. 4Departments of Epidemiology and Medicine, Boston University Medical Center, Boston MA
  5. 5Dana Farber/Harvard Cancer Center, Boston MA
  6. 6Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm
  1. Correspondence to: J R Stark stark{at}hsph.harvard.edu

    Two long awaited randomised trials of PSA screening have reported this year. However, as Jennifer Stark and colleagues explain, the results are unlikely to end the controversy over the benefits and harms of testing

    The introduction of prostate specific antigen (PSA) testing as a screening tool has transformed the clinical landscape of prostate cancer. Screening allows prostate cancer to be diagnosed many years earlier, offering hope that a newly detected cancer is still localised to the prostate when treatment is curative. However, screening has also led to considerable false positive results and extensive overdiagnosis of disease that would not otherwise emerge clinically. We summarise current screening guidelines and review the evidence of benefit and harm of PSA testing.

    Current screening guidelines and practices

    The US Food and Drug Administration approved PSA testing to monitor progression of cancer among men with prostate cancer in 1986 and for early detection of prostate cancer in 1994. Nevertheless, many agencies in the US and Europe do not recommend routine prostate cancer screening (box 1). The European Association of Urology, for instance, states that “Current published data are insufficient to recommend the adoption of population screening for prostate cancer as a public health policy due to the large overtreatment effect.” The notable exception is the American Urological Association,1 which updated its guidelines after the publication of the results of two recent randomised trials2 3 of prostate cancer screening, and now recommends annual screening for men aged 40 and older who have a life expectancy of at least 10 years.

    Box 1 International recommendations on screening for prostate cancer

    • American Cancer Society—Does not support routine testing for prostate cancer. Recommends discussion with doctor regarding benefits and limitations of early detection with an offer of a PSA test beginning at:

      • Age 50 for average risk men with life expectancy of at least 10 years

      • Age 45 for men …

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