In contrast, in the multicenter ERSPC (European Randomized Study of Screening for Prostate Cancer) trial, which involved 182,160 men aged 50-74 years, those aged 55-69 who received PSA testing once every 4 years had a 20% reduction in prostate cancer–specific mortality (but not overall mortality) at 9 years, with the result maintained at 11 years (N. Engl. J. Med. 2009;360:1320-8).
In a subanalysis of the Swedish ERSPC center involving 20,000 men after 14 years of follow-up, statistically significant differences in prostate cancer–specific mortality of up to 56% were detected in favor of the PSA-screened (Lancet Oncol. 2010;11:725-32).
The AHRQ systematic review reported that the false-positive rates associated with PSA screening were 12.9% in the PLCO trial after four rounds of screening, and 12.5% in one center of the ERSPC after three rounds of screening. In PLCO, harms associated with diagnostic evaluations, including biopsy, were reported to be infection, bleeding, and urinary difficulty (68 events per 10,000 evaluations). In one center of the ERSPC trial, among 5,802 biopsies performed, reported harms were fever (3.5%), urinary retention (0.4%), hospitalization for signs of prostatitis or urosepsis (0.5%), and hematuria (22.6%) and hematospermia (50.4%) more than 3 days after biopsy.
"It is important to recognize that risk-benefit ratios can be substantially affected in studies and in practice by altering screening strategies, by changing treatment strategies, by changing measurement approaches, and by considering different lengths of follow-up.
"The ASCO guideline suggests that we can improve outcomes by becoming wiser about how we screen, wiser about who we treat, wiser about avoiding and managing harms of treatment, and wiser about how we communicate with patients," Dr. Basch said in the interview.
He added that physicians should not offer or order PSA screening unless they are "prepared to engage in shared decision making that enables an informed choice by patients." The current decision aid, designed to assist in that conversation, is a first version. "It is ASCO’s hope that it will be tested and refined in the future to become as efficient and useful as possible. It is also a hope that provision of accurate information to clarify decision making will make the PSA discussion more efficient and meaningful."
Hopefully, this process will be made easier in the future with new screening tests and new ways of using the PSA test that are currently under evaluation. Also, Dr. Basch said, "more mature results of ongoing screening studies, final results of treatment studies, and investigations of active surveillance approaches are all likely to improve our understanding of how screening and treatment can be optimized."
Dr. Basch reported no relevant disclosures, but one other ASCO panel member, Dr. Andrew Vickers, disclosed financial ties to GlaxoSmithKline and Genomic Health. USPHTF members such as Dr. LeFevre are vetted for disclosure.