A new study has confirmed the effectiveness of Prostate-specific Antigen (PSA) screening in reducing prostate cancer mortality.
The retrospective cohort study of over 400,000 men, as published in Elsevier’s Urology® journal,1 set out to re-examine the value of PSA screening, to determine the optimal screening interval and the appropriate age groups to be screened.
The data indicates that yearly PSA screening was the interval of choice, reducing prostate cancer deaths by 64% for men aged 55-75 years and all-cause mortality by 24%. No benefits were associated with screening for men under 55 years.
Whilst these findings are significant, and echo current public sentiment around prostate cancer screening, there are a number of discussion points worthy of further consideration.
The first is the proposed response to a concern raised by previous data – the European Randomized Study of Screening for Prostate Cancer (ERSPC) and the National Cancer Institute (NCI) – which was that screening resulted in an increased number of clinically insignificant prostate cancers. The unnecessary treatment of these led to the United States Preventive Services Task Force (USPSTF) recommend against PSA screening in 2012.
This latest study therefore recommends active surveillance to prevent over-treatment, suggesting that 36% of patients with a new diagnosis are candidates for active surveillance, 30% of whom will ultimately have treatment for progression.
In addition, the study raises a discussion around what happens after an elevated PSA is identified. Should all men be biopsied or just some, stating “What is important to find is cancer worth treating, which first and foremost depends on an assessment of the patient.”
These discussion points indicate that the pathway for prostate biopsy should be considered in equal part to PSA screening in risk stratifying patients to reduce ‘unnecessary’ treatment of indolent disease and identify the optimal treatment option for patients with aggressive disease.
Multiparametric MRi2 followed, where appropriate, by a systematic biopsy of the entire gland, through latest innovation such as the PrecisionPoint™ transperineal biopsy system, provides a more accurate assessment of incidents of cancer, which allows consultants and patients alike to consider the full range of available and appropriate treatment options.
In males in the UK, prostate cancer is the most common cancer. Whilst incidence rates are increasing, 40% of cases in England and Northern Ireland and 60% of cases in Scotland are diagnosed at a late stage. The importance of annual PSA screening for men over 55 years can therefore not be underestimated. However, of equal significance in reducing prostate cancer mortality is the prostate biopsy. Without a commensurate focus on ensuring that patients with elevated PSA are appropriately risk stratified – of which systematic biopsy is a fundamental component – we will fail to realise the optimal patient treatment pathway.
References
- New Evidence for the Benefit of Prostate-specific Antigen Screening: Data From 400,887 Kaiser Permanente Patients, Paul F Alpert, UROLOGY 118: 119–126, 2018. © 2018 https://www.sciencedirect.com/science/article/pii/S0090429518303765
- PROMIS shows MRI scan could help a quarter of men safely avoid prostate biopsy. http://www.ctu.mrc.ac.uk/news/2017/promis_results_19012017
