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. 2014 Mar 28:348:g2296.
doi: 10.1136/bmj.g2296.

Influence of blood prostate specific antigen levels at age 60 on benefits and harms of prostate cancer screening: population based cohort study

Sigrid Carlsson  1 , Melissa Assel, Daniel Sjoberg, David Ulmert, Jonas Hugosson, Hans Lilja, Andrew Vickers
Affiliations

Influence of blood prostate specific antigen levels at age 60 on benefits and harms of prostate cancer screening: population based cohort study

Sigrid Carlsson et al. BMJ. .

Abstract

Objective: To determine the relative risks of prostate cancer incidence, metastasis, and mortality associated with screening by serum prostate specific antigen (PSA) levels at age 60.

Design: Population based cohort study.

Setting: General male population of Sweden taking part in a screening trial in Gothenburg or participating in a cardiovascular study, the Malmö Preventive Project.

Participants: The screened group consisted of 1756 men aged 57.5-62.5 participating in the screening arm of the Gothenburg randomized prostate cancer screening trial since 1995. The unscreened group consisted of 1162 men, born in 1921, participating in the Malmö Preventive Project, with PSA levels measured retrospectively in stored blood samples from 1981.

Intervention: PSA screening versus no screening.

Main outcome measures: Incidence rate ratios for the effect of screening on prostate cancer diagnosis, metastasis, and death by PSA levels at age 60.

Results: The distribution of PSA levels was similar between the two cohorts. Differences in benefits by baseline PSA levels were large. Among men with baseline levels measured, 71.7% (1646/2295) had a PSA level <2 ng/mL. For men aged 60 with PSA level <2 ng/mL, there was an increase in incidence of 767 cases per 10,000 without a decrease in prostate cancer mortality. For men with PSA levels ≥ 2 ng/mL, the reduction in cancer mortality was large, with only 23 men needing to be screened and six diagnosed to avoid one prostate cancer death by 15 years.

Conclusions: The ratio of benefits to harms of PSA screening varies noticeably with blood PSA levels at age 60. For men with a PSA level <1 ng/mL at age 60, no further screening is recommended. Continuing to screen men with PSA levels >2 ng/mL at age 60 is beneficial, with the number needed to screen and treat being extremely favourable. Screening men with a PSA level of 1-2 ng/mL is an individual decision to be based on a discussion between patient and doctor.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; HL holds patents for free prostate specific antigen (PSA), kallikrein related peptidase 2, and intact PSA assays, and along with AV, is named as co-inventor on a patent application for intact/nicked PSA assays and for a statistical method for predicting the result of a prostate biopsy.

Figures

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Fig 1 Cumulative risk of prostate cancer diagnosis
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Fig 2 Cumulative risk of prostate cancer metastasis
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Fig 3 Cumulative risk of prostate cancer death
See this image and copyright information in PMC

Comment in

References

    1. Hugosson J, Carlsson S, Aus G, Bergdahl S, Khatami A, Lodding P, et al. Mortality results from the Göteborg randomised population-based prostate-cancer screening trial. Lancet Oncol 2010;11:725-32. - PMC - PubMed
    1. Schroder FH, Hugosson J, Roobol MJ, Tammela TL, Ciatto S, Nelen V, et al. Prostate-cancer mortality at 11 years of follow-up. N Engl J Med 2012;366:981-90. - PMC - PubMed
    1. Schröder FH, Hugosson J, Roobol MJ, Tammela TL, Ciatto S, Nelen V et al. Screening and prostate-cancer mortality in a randomized European study. N Engl J Med 2009;360:1320-8. - PubMed
    1. Loeb S, Carter HB, Catalona WJ, Moul JW, Schroder FH. Baseline prostate-specific antigen testing at a young age. Eur Urol 2012;61:1-7. - PubMed
    1. Lilja H, Ulmert D, Bjork T, Becker C, Serio AM, Nilsson JA, et al. Long-term prediction of prostate cancer up to 25 years before diagnosis of prostate cancer using prostate kallikreins measured at age 44 to 50 years. J Clin Oncol 2007;25:431-6. - PubMed

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