EAU 2017: Special session of the Prostate Cancer Prevention Group: ERSPC
In the last update of the ERSPC with follow-up truncated at 13 years, a significant 21% relative reduction in prostate cancer was demonstrated in intention to screen analyses, and 27% in men who actually attended screening. The absolute risk reduction of death from prostate cancer at 13 years was 1.28 fewer prostate cancer deaths per 1,000 men randomized. A total of 781 men needed to be invited to screening and 27 to be diagnosed with prostate cancer to avert one death from the disease. These numbers are predicted to go lower in the next update of the study incorporating 16 years of follow-up.
The main disadvantage of screening is the increased risk of over-diagnosis of prostate cancer due to screening, meaning detection of non-significant low risk cancers. Despite showing a clear prostate cancer mortality reduction, the findings were not sufficient to justify population-based screening. The harms of screening will need to be further assessed and strategies to overcome over-diagnosis and overtreatment will need to be implemented. In the interim, well-informed men suitable for screening should be able to undergo PSA testing if they wish, after careful consideration of the pros and cons.
Dr. Hugosson emphasized on the incidence of prostate cancer after termination of screening which has doubled. He also noted that there is a difference in the intensity of screening in different European countries. This translates into differences in mortality reduction. Additionally, the number of PSA tests is also correlated to mortality. Results show that the better patients are screened and the more PSA blood test are done, less death occurs.
Intense screening can result in over-diagnosis. The risk of over-diagnosis is largest the first time a man is screened. Additionally, this risk is closely related to age, and continuation of screening in older men will strongly increase the risk of over diagnosis. Opting to perform screening with longer intervals will not decrease the risk of over-diagnosis but jeopardize patients by causing them to be diagnosed in a non-curable phase. When balancing over-diagnosis and efficacy an intense screening program seems more favorable. It is our goal to strive and reach the delicate balance between proper moderate screening and over-diagnosis.
Dr. Hugosson concluded by stating some important additional points including the fact that current biopsy technique is blind with a false negative of 10-30% and must be improved. He added that sequential screening with biomarkers followed by imaging to avoid biopsy should be the next step and a randomized trial assessing this strategy is currently underway.
Presented by: J. Hugosson, Göteborg (SE)
Written by: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto
Twitter: @GoldbergHanan
at the #EAU17 -March 24-28, 2017- London, England