Younger and at-risk men benefit from PSA screening to detect prostate cancer

Screening younger men and men at risk of prostate cancer can be beneficial in reducing metastatic cancer and deaths and should not be abandoned, states an article published in CMAJ (Canadian Medical Association Journal). The United States Preventive Services Task Force, which last issued prostate screening guidelines in 2008, recently issued a draft recommendation against prostate-specific antigen (PSA) screening for men of all ages. However, the American Cancer Society and the American Urological Association both recommend that men be given a choice about whether they should be screened. The United Kingdom and Australia take the approach of informed choice to enable patients to make their own decisions. The Canadian Task Force on Preventive Health Care, which recommended against PSA screening in its last guidelines in 1994, is expected to issue updated recommendations in 2013. Recent research from a large, high-quality randomized trial of 162 243 men in Europe aged 55 to 69 years indicates that screening reduces deaths caused by prostate cancer. Other trials, such as the US Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial, showed no benefit in screening. "Cancer-specific mortality, not overall mortality, is the primary outcome in screening trials," writes Dr. Monique Roobol, Department of Urology, Erasmus University Medical Centre, Rotterdam, the Netherlands, with coauthors. "Because deaths from prostate cancer are a small proportion of all deaths, comparisons of overall mortality are underpowered. Thus, a screening program that reduces cancer-specific mortality should not be stopped because of a lack of reduction in overall mortality." Screening can also reduce the incidence of metastatic cancer, as the European Randomized Study of Screening for Prostate Cancer underscores, which found a 41% reduction in metastatic disease at diagnosis of the cancer with screening. The authors write that the decision to screen or not to screen should be individual as screening is not appropriate for every man. For elderly men with several medical issues, screening may be more harmful than beneficial, but for younger, healthy men, screening can reduce death from prostate cancer. Healthy younger men also are at lower risk of complications from biopsies and treatments compared with older men. "Rather than abandoning a screening test that reduces death and suffering, efforts should be focused on selecting patients more carefully," conclude the authors. "Screening should be encouraged for healthy younger men and men with risk factors (e.g., black ancestry, positive family history) and discontinued for elderly men with multiple comorbidities and limited life expectancy."