Screening for prostate cancer: time to put all the data on the table

Screening for prostate cancer with the prostate specific antigen (PSA) test remains controversial, and guidance varies around the world. One urology association in Australia and New Zealand recommends offering PSA testing to men aged 55-69,1 while the US Preventive Services Task Force recommends against its use, giving it a D recommendation—that is, “moderate or high certainty that the service has no net benefit or that the harms outweigh the benefit.”2 How are patients and physicians to reconcile these divergent views?

On the one hand, 2-3% of men die from painful metastatic prostate cancer at a median age of 80,3 4 and invariably men want to take all reasonable steps to avoid this. On the other hand, the incidence of disease is 20-25% in a random population within the generally accepted normal range of PSA of 0-4 ng/ml5; overdiagnosis and overtreatment are common; the benefits of radical treatments are small; and the common toxicities of radical treatments, such as impotence and urinary incontinence, are a concern for many men.6 7

With these considerations in mind, physicians depend largely on the evidence from three high profile randomised clinical trials to advise men whether to be screened, and perhaps treated, for early stage prostate cancer.8 9 10 Although two of these trials—the European Randomised Study of Screening for Prostate Cancer (ERSPC)9 and the Gothenburg trial10—reported a benefit for PSA screening, the large US Prostate, Lung, Colorectal and Ovarian (PLCO) trial found no benefit.8 As the debate about PSA screening for prostate cancer continues, we believe that there are questions that …