Elsevier

European Urology

Volume 61, Issue 4, April 2012, Pages 652-661
European Urology

Platinum Priority – Collaborative Review – Prostate Cancer
Editorial by Ian M. Thompson and Donna P. Ankerst on pp. 662–663 of this issue
Risk-Based Prostate Cancer Screening

https://doi.org/10.1016/j.eururo.2011.11.029Get rights and content

Abstract

Context

Widespread mass screening of prostate cancer (PCa) is not recommended because the balance between benefits and harms is still not well established. The achieved mortality reduction comes with considerable harm such as unnecessary biopsies, overdiagnoses, and overtreatment. Therefore, patient stratification with regard to PCa risk and aggressiveness is necessary to identify those men who are at risk and may actually benefit from early detection.

Objective

This review critically examines the current evidence regarding risk-based PCa screening.

Evidence acquisition

A search of the literature was performed using the Medline database. Further studies were selected based on manual searches of reference lists and review articles.

Evidence synthesis

Prostate-specific antigen (PSA) has been shown to be the single most significant predictive factor for identifying men at increased risk of developing PCa. Especially in men with no additional risk factors, PSA alone provides an appropriate marker up to 30 yr into the future. After assessment of an early PSA test, the screening frequency may be determined based on individualized risk. A limited list of additional factors such as age, comorbidity, prostate volume, family history, ethnicity, and previous biopsy status have been identified to modify risk and are important for consideration in routine practice. In men with a known PSA, risk calculators may hold the promise of identifying those who are at increased risk of having PCa and are therefore candidates for biopsy.

Conclusions

PSA testing may serve as the foundation for a more risk-based assessment. However, the decision to undergo early PSA testing should be a shared one between the patient and his physician based on information balancing its advantages and disadvantages.

Introduction

Prostate cancer (PCa) is the second most frequently diagnosed cancer and the sixth leading cause of cancer death in men, accounting for 14% (903 500) of total new cancer cases and 6% (258 400) of total cancer deaths in men in 2008 [1].

PCa has a variable natural history, ranging from indolent to strikingly aggressive with a long preclinical phase. Because we are still awaiting a breakthrough in the treatment of advanced disease, earlier detection of clinically significant disease currently seems to afford the best opportunity of stemming the tide. In general, there are two approaches to early detection: screen everyone within a certain age range (eg, breast cancer and cervical cancer) or screen selectively based on risk factors (eg, lung cancer).

For PCa screening, evidence of mortality reduction was shown by prostate-specific antigen (PSA)–based screening in the European Randomized Study of Screening for Prostate Cancer (ERSPC) and the overlapping Göteborg trial [2], [3], [4]. Although several associations in Europe and the United States have updated their guidelines regarding PCa screening (Table 1), widespread mass screening is not recommended because the achieved mortality reduction comes with considerable harm such as unnecessary biopsies, overdiagnoses, and subsequent overtreatment [3], [5], [6]. Therefore, patient stratification with regard to PCa risk and aggressiveness is necessary to identify those men who are at risk and may actually benefit from early detection [7], [8]. In other words, a risk-based strategy is necessary to prevent unnecessary PSA testing and widespread overdiagnoses.

With the current screening algorithm applied in the ERSPC, the relative mortality reduction after a median follow-up of 9 yr is modest at 20–30% [2], [3]. A recent study from the ERSPC group showed that noncompliance with the screening protocol and aggressive interval cancers were attributed to a significant proportion of the PCa deaths in the intervention arm [9]. With a risk-based strategy, we may improve the screening effect. First, those with intermediate and high risk may be screened with a shorter interval, which may lead to fewer aggressive interval cancers. Second, the compliance might increase among those at high risk if they were informed of their risk status, resulting in fewer nonattendees after being screened once. This review critically examines the current evidence regarding risk-based PCa screening.

Section snippets

Evidence acquisition

To apply a risk-based screening strategy, one must first identify the risk factors. Thus in this review we considered articles that evaluated factors predicting the presence of PCa. It is important to realize that some markers predict the risk of either current or future PCa, and others have predictive value in both cases. We also highlighted some of the most frequently used prediction tools that assess the chance of having PCa.

A search of the literature was performed using the Medline database

Age

The association between increasing age and PCa risk is very strong [10], [11], [12], [13]. However, across the relatively narrow age range typically encountered in many screening programs, age may not be an independent predictor of risk. Schröder et al. showed that age (per year or per decade) was not a statistically significant predictor for PCa in men 55–70 yr at the initial screen, unlike PSA, previous negative biopsy (yes or no), and prostate volume, which were predictive [14].

We do not yet

Conclusions

To date, PSA has been shown to be the single most significant predictive factor for identifying men at increased risk of developing PCa. Especially in men with no additional risk factors, PSA alone provides an appropriate marker up to 30 yr into the future. After assessment of an early PSA test, the screening frequency may be determined based on individualized risk. Although retrospective data strongly point toward the potential of risk-stratifying men, outcomes such as unnecessary testing,

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