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The Association of County-Level Prostate-Specific Antigen Screening with Metastatic Prostate Cancer and Prostate Cancer Mortality - Beyond the Abstract

The debate over population-based PSA screening has focused on concerns regarding overdiagnosis and overtreatment of prostate cancer in light of conflicting evidence of benefit in large randomized trials.1,2 Shifting guideline recommendations have led to a decline in screening that appears, however, to be linked to concerning increases in advanced prostate cancer in the United States.3–5

In the absence of compelling level I evidence, high-quality epidemiological studies have sought to further evaluate population-level effects of PSA screening. In this study, we used validated methodology to develop a multilevel mixed effects model with poststratification using the Behavioral Risk Factor Surveillance System (BRFSS) and US Census data to estimate county-level PSA screening rates adjusted for age, race, ethnicity, and county-level poverty rates. This methodology, which provides accurate small-area estimates of health behaviors, enables assessment of the association of county-level screening rates with county-level prostate cancer outcomes from SEER and NCI/CDC State Cancer Profiles.6–8

We found that counties with 10% higher PSA screening rates from 2004-2012 were associated with 14% lower incidence of advanced prostate cancer from 2015-2019 and 10% lower prostate cancer-specific mortality from 2016-2020. Given the long natural history of prostate cancer, the long lag time in this study is an important advantage in understanding the impact of PSA screening. Despite the limitations inherent to this type of model, this study has substantial clinical implications adding to the growing body of literature in support of population-based PSA screening. Taken together, high-quality ecological and epidemiological studies suggest a real-world benefit of PSA screening in reducing rates of advanced prostate cancer and prostate cancer mortality.

Written by: Benjamin V. Stone, MD, Department of Urology, Brigham and Women's Hospital & Department of Urology, Massachusetts General Hospital

References:

  1. Schröder FH, Hugosson J, Roobol MJ, et al. Screening and prostate cancer mortality: results of the European Randomised Study of Screening for Prostate Cancer (ERSPC) at 13 years of follow-up. Lancet. 2014;384(9959):2027-2035.
  2. Andriole GL, Crawford ED, Grubb RL, et al. Mortality results from a randomized prostate-cancer screening trial. N Engl J Med. 2009;360(13):1310-1319.
  3. Hu JC, Nguyen P, Mao J, et al. Increase in Prostate Cancer Distant Metastases at Diagnosis in the United States. JAMA Oncol. 2017;3(5):705-707.
  4. Desai MM, Cacciamani GE, Gill K, et al. Trends in Incidence of Metastatic Prostate Cancer in the US. JAMA Netw Open. Published online 2022.
  5. Jemal A, Culp MBB, Ma J, Islami F, Fedewa SA. Prostate Cancer Incidence 5 Years After US Preventive Services Task Force Recommendations Against Screening. JNCI Journal of the National Cancer Institute. 2021;113(1):64.
  6. Berkowitz Z, Zhang X, Richards TB, Nadel M, Peipins LA, Holt J. Multilevel small-area estimation of colorectal cancer screening in the United States. Cancer Epidemiol Biomarkers Prev. 2018;27(3):245.
  7. Zhang X, Holt JB, Lu H, et al. Multilevel Regression and Poststratification for Small-Area Estimation of Population Health Outcomes: A Case Study of Chronic Obstructive Pulmonary Disease Prevalence Using the Behavioral Risk Factor Surveillance System. Am J Epidemiol. 2014;179(8):1025-1033.
  8. Zhang X, Holt JB, Yun S, Lu H, Greenlund KJ, Croft JB. Validation of Multilevel Regression and Poststratification Methodology for Small Area Estimation of Health Indicators From the Behavioral Risk Factor Surveillance System. Am J Epidemiol. 2015;182(2):127.
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