Landmarks in prostate cancer screening

Prostate-specific antigen (PSA) has been widely applied to diagnosis and follow-up of prostate cancer, which led to research on its potential role in the early detection of the disease and its use in screening. The value of PSA screening in reducing disease mortality is controversial and several studies have been conducted to determine the actual benefits. One of the early studies, the Tyrol Screening Study conducted in 1993, showed that during 2004 to 2008 there was a significant reduction in prostate cancer mortality in men aged >60 years compared with the mortality rate during 1989 to 1993. Two studies that showed no benefit of screening in terms of prostate cancer death were conducted in Sweden in 1987 and 1988. The Prostate, Lung, Colorectal, and Ovarian Screening Study conducted in the USA during 1993 to 2001 and involving 76 693 men showed no benefit of screening at 10 years but the trial can be criticised due to excessive contamination of the unscreened group. In contrast, the European Randomized Study of Screening for Prostate Cancer (ERSPC), the largest randomised study with 162 388 participants study, showed that at a median follow-up of 9 years a prostate cancer mortality reduction of 20% resulted (P = 0.04). In an analysis limited to four ERSPC centres with a follow-up of 12.0 years, screening resulted in an overall reduction of metastatic disease of 31%. The arguments against PSA screening include the risks associated with screening tests themselves, e. g. biopsy-related haematuria, urosepsis, and over diagnosis and overtreatment of prostate cancer. The overall evidence points in favour of PSA screening and steps can be taken to avoid overtreatment by offering patients active surveillance.