Screening decreases prostate cancer mortality: 11-year follow-up of the 1988 Quebec prospective randomized controlled trial

Preliminary study on miRNA in prostate cancer

OBJECTIVE

To screen for miRNAs differentially expressed in prostate cancer and prostate hyperplasia tissues and to validate their association with prostate cancer.

METHODS

Patients diagnosed by pathology in the Department of Urology of the First Affiliated Hospital of Xinjiang Medical University from October 2021 to June 2022 were selected, and their general clinical information, blood samples, and prostate tissue samples were collected. miRNA microarray technology was performed to obtain differentially expressed miRNAs in prostate cancer and hyperplasia tissues, and miRNAs to be studied were screened by microarray results and review of relevant literature. The detection of miRNA expression in the patients' blood and prostate tissue samples was measured. The miRNA-222-mimics were transfected into PC3 cells, and cell biology experiments such as CCK8, scratch, Transwell, and flow cytometry were performed to detect the effects of overexpressed miRNA-222 on the growth and proliferation, invasive ability, apoptotic ability, and metastatic ability of prostate cancer cells.

RESULTS

The results of the miRNA microarray showed that there were many differentially expressed miRNAs in prostate cancer and hyperplasia tissues, and four miRNAs, miRNA-144, miRNA-222, miRNA-1248, and miRNA-3651 were finally selected as the subjects by reviewing relevant literature. The results showed that the expression of miRNA-222 in prostate cancer tissues was lower than that in prostate hyperplasia tissues (P < 0.05). The expression of miRNA-222, miRNA-1248, and miRNA-3651 in blood samples of prostate cancer patients was lower than that in prostate hyperplasia patients (P < 0.05). The analysis results indicated that the f/t ratio and the relative expression of miRNA-222 and miRNA-1248 were independent influences of prostate cancer (P < 0.05), in which overexpression of miRNA-222 decreased the proliferative, invasive, and metastatic abilities of PC3 cells and enhanced the level of apoptosis of cancer cells.

CONCLUSIONS

Although there was no significant change in the overall incidence of prostate cancer in this study, significant changes occurred in the incidence of prostate cancer with different characteristics. In addition, the nomogram prediction model of prostate cancer-specific survival rate constructed based on four factors has a high reference value, which helps physicians to correctly assess the patient-specific survival rate and provides a reference basis for patient diagnosis and prognosis evaluation.

Multi-marker risk-based screening for prostate cancer

OBJECTIVE

To determine prostate cancer screening performance using prostate specific antigen (PSA) along with other markers, expressing markers in age-specific multiples of the median (MoM), and age.

METHODS

A prospective nested case-control study used stored serum from 571 men who died of, or with history of, prostate cancer (cases), and 2169 matched controls. Total, free and intact PSA, human kallikrein-related peptidase 2 (hK2), and microseminoprotein were measured and converted into MoM values. Screening marker distribution parameters were estimated in cases and controls. Monte Carlo simulation used these in a risk-based algorithm to estimate screening performance (detection rates [DRs] and false-positive rates [FPRs]).

RESULTS

Almost all (99%) cases occurred aged ≥55. Marker values were similar in cases who did and did not die of prostate cancer. Combining age, total PSA and hK2 MoM values (other markers added little or no discrimination) yielded a 1.2% FPR (95% CI 0.2-4.8%) for a 90% DR (59-98%) in men who died of or with a prostate cancer diagnosis within 5 years of blood collection (risk cut-off 1 in 20), two-thirds less than the 4.5% FPR using total PSA alone measured in ng/ml for the same 90% DR (cut-off 3.1 ng/ml). Screening performance over 10 years yielded a 33% (22-46%) FPR for a 90% DR.

CONCLUSION

Screening performed up to every 5 years from age 55 using the multi-marker risk-based screening algorithm for future prostate cancer achieves a high DR and a much lower FPR than using PSA alone, resulting in reductions in overdiagnosis and overtreatment.

Prostate cancer follow-up costs in Germany from 2000 to 2015

Purpose

The main objective of this study is to estimate and evaluate 10-year follow-up costs after prostate cancer treatment with curative (surgery, radiotherapy) and non-curative intent (hormone, androgen deprivation) per patient in Germany in 2000, 2008, and 2015.

Methods

Prostate cancer follow-up recommendations were extracted from the European Association of Urology guidelines from 2000 to 2015. Per patient costs were calculated with a detailed micro-costing approach considering direct and indirect medical expenses. Input parameters were derived from expert interviews, literature research, and official scales of tariffs. Costs for insurers, providers, and payers were included to estimate societal costs.

Results

Mean 10-year follow-up costs per patient after treatment with curative intent amounted to EUR 4415 in 2000, EUR 4224 in 2008 (p < 0.001), and EUR 5159 in 2015 (p < 0.001). Costs after hormone therapy with metastasis cumulated to EUR 10,846 in 2000, EUR 9818 in 2008 (p < 0.001), and EUR 11,978 in 2015 (p < 0.001). While insurers covered 37% of costs in 2000 (EUR 1664), only 23% of costs were reimbursed in 2015 (EUR 1195; p < 0.001). Cost sources mainly included consultations (55%), transportation (18%), and imaging (27%).

Conclusion

Early detection and advances in prostate cancer treatment increased 10-year survival rates beyond 80% in Germany, ultimately expanding the number of survivors requiring follow-up. Statutory insurers reacted by decreasing the reimbursement rates to reduce per patient cost by up to 46%. Consequently, the economic burden was mainly shifted to payers and providers.

Implications for Cancer Survivors

Equitable and effective follow-up schedules covered by insurance funds are necessary to care for prostate cancer patients.

Lower Urinary Tract Functional Assessment of Men Undergoing Radical Prostatectomy: Correlation of Preoperative Clinical and Urodynamic Parameters

PURPOSE

To assess baseline clinical and urodynamic profiles of a contemporary cohort of men undergoing radical prostatectomy (RP) as part of the ROSE (Robotic and Open Surgery for Prostate Cancer: A Prospective, Multi-centre, Comparative Study of Functional and Oncological Outcomes) study.

METHODS

Men with localized prostate cancer undergoing RP were prospectively recruited to undergo clinical assessment and urodynamic testing prior to surgery as part of a clinical trial. The International Prostate Symptoms Score (IPSS) was used to determine participants' degree of lower urinary tract symptoms (LUTS).

RESULTS

Eighty-five men with a median age of 64.5 years and a median prostate-specific antigen level of 6.3 ng/mL were prospectively recruited. Of patients with complete baseline data, 36 (50.7%), 28 (39.4%), and 7 (9.9%) had mild (IPSS<8), moderate (IPSS 8-19), and severe (IPSS>20) LUTS, respectively. Obstruction was identified in 18 men (29.5%), and 9 (14.8%) showed detrusor underactivity. Of the 15 patients with detrusor overactivity, 12 (80%) reported overactive bladder (OAB). Of men with urodynamic obstruction, 5 (31.3%), 10 (62.5%), and 1 (6.3%) reported mild, moderate, and severe LUTS, respectively. Of men without OAB, 4 (11.8%, P=0.002) showed filling phase abnormalities, 13 (46.4%, P=0.611) had flow rates of <15 mL/sec, and 7 (30.4%, P=0.767) showed obstruction. Of men with mild or no LUTS, 5 (20%, P=0.072) showed obstruction and 4 (16%, P=0.524) showed poor contractility.

CONCLUSION

LUTS and OAB were common in men with localized prostate cancer undergoing RP. Detrusor overactivity and urodynamic filling phase abnormalities were strongly correlated with OAB. IPSS did not show a strong correlation with bladder outflow obstruction or detrusor underactivity. Urodynamic filling abnormalities were found in 11.8% of men without OAB. Symptomatic and functional assessment may therefore have a role in the preoperative counselling of patients and possibly guide postoperative management of LUTS, especially if OAB is present.

Prostate-specific antigen testing and opportunistic prostate cancer screening: a cohort study in England, 1998-2017

Background

Prostate cancer is a leading cause of cancer- related death. Interpreting the results from trials of screening with prostate-specific antigen (PSA) is complex in terms of defining optimal prostate cancer screening policy.

Aim

To assess the rates of, and factors associated with, the uptake of PSA testing and opportunistic screening (that is, a PSA test in the absence of any symptoms) in England between 1998 and 2017, and to estimate the likely rates of pre-randomisation screening and contamination (that is, unscheduled screening in the ‘control’ arm) of the UK-based Cluster Randomised Trial of PSA Testing for Prostate Cancer (CAP).

Design and setting

Open cohort study of men in England aged 40–75 years at cohort entry (1998–2017), undertaken using the QResearch database.

Method

Eligible men were followed for up to 19 years. Rates of PSA testing and opportunistic PSA screening were calculated; Cox regression was used to estimate associations.

Results

The cohort comprised 2 808 477 men, of whom 631 426 had a total of 1 720 855 PSA tests. The authors identified that 410 724 men had opportunistic PSA screening. Cumulative proportions of uptake of opportunistic screening in the cohort were 9.96% at 5 years’, 22.71% at 10 years’, and 44.13% at 19 years’ follow-up. The potential rate of contamination in the CAP control arm was estimated at 24.50%.

Conclusion

A substantial number of men in England opt in to opportunistic prostate cancer screening, despite uncertainty regarding its efficacy and harms. The rate of opportunistic prostate cancer screening in the population is likely to have contaminated the CAP trial, making it difficult to interpret the results.

Increasing incidence of prostate cancer in Taiwan: A study of related factors using a nationwide health and welfare database

Over the past decades, the incidence of prostate cancer in Taiwan kept rising. Many possible factors including the utility of prostate specific antigen tests, lifestyle remodeling, and patient's comorbidities may contribute to the increasing of incidence or prostate cancer. We aim to use the nationwide Health and Welfare Database (HWD) to investigate possible associated factors.We used HWD, a nationwide database of medical information, to assess the incidence of prostate cancer, utilization of prostate-specific antigen (PSA) test, and underlying diseases of patients and to evaluate whether there was a common trend among these factors.In total, 32,508 patients with newly diagnosed prostate cancer from 2006 to 2013 were identified. The incidence rate of prostate cancer per 100,000 men increased from 35.47 in 2006 to 52.87 in 2012. The number of patients with prostate cancer and underlying diseases related to metabolic syndrome increased every year. The number of total PSA tests and patients undergoing PSA testing, as well as average times of PSA testing per person in the whole population, increased every year. The average PSA test times of patients with newly diagnosed prostate cancer within 3 years before the diagnosis of prostate cancer also increased every year. There was a high correlation between the average PSA test times and the number of patients with newly diagnosed prostate cancer (r = 0.9734).The trends of incidence of prostate cancer, utilization of PSA testing, and underlying diseases related to metabolic syndrome at the diagnoses of cancer were similar, increasing every year in the study period. The results suggested that increasing use of PSA tests may increase the diagnosis of prostate cancers. Underlying diseases related to metabolic syndrome might also affect the incidence of prostate cancer.

Rethinking prostate cancer screening: could MRI be an alternative screening test?

In the past decade rigorous debate has taken place about population-based screening for prostate cancer. Although screening by serum PSA levels can reduce prostate cancer-specific mortality, it is unclear whether the benefits outweigh the risks of false-positive results and overdiagnosis of insignificant prostate cancer, and it is not recommended for population-based screening. MRI screening for prostate cancer has the potential to be analogous to mammography for breast cancer or low-dose CT for lung cancer. A number of potential barriers and technical challenges need to be overcome in order to implement such a programme. We discuss different approaches to MRI screening that could address these challenges, including abbreviated MRI protocols, targeted MRI screening, longer rescreening intervals and a multi-modal screening pathway. These approaches need further investigation, and we propose a phased stepwise research framework to ensure proper evaluation of the use of a fast MRI examination as a screening test for prostate cancer.

Screening for prostate cancer: History, evidence, controversies and future perspectives toward individualized screening

Differences in the incidence and mortality rate of prostate cancer between the USA and Japan have been decreasing over time, and were only twofold in 2017. Therefore, countermeasures against prostate cancer could be very important not only in Western countries, but also in developed Asian countries. Screening for prostate cancer in the general population using transrectal ultrasonography, digital rectal examination and/or prostate acid phosphatase began in Japan in the early 1980s, and screening with prostate-specific antigen and digital rectal examination has been widespread in the USA since the late 1980s. Large- and mid-scale randomized controlled trials on screening for prostate cancer began around 1990 in the USA, Canada and Europe. However, most of these studies failed as randomized controlled trials because of high contamination in the control arm, low compliance in the screening arm or insufficient screening setting about screening frequency and/or biopsy indication. The best available level 1 evidence is data from the European Randomized Study of Screening for Prostate Cancer and the Göteborg screening study. However, several non-urological organizations and lay media around the world have mischaracterized the efficacy of prostate-specific antigen screening. To avoid long-term confusion about screening for prostate cancer, leading professional urological organizations, including the Japanese Urological Association, are moving toward the establishment of an optimal screening system that minimizes the drawbacks of overdetection, overtreatment and loss of quality of life due to treatment, and maximizes reductions in the risk of death as a result of prostate cancer and the development of metastatic prostate cancer.

The effects of shared decision-making compared to usual care for prostate cancer screening decisions: a systematic review and meta-analysis

Background

Shared decision-making (SDM) is recommended for men facing prostate cancer (PC) screening decisions. We synthesize the evidence on the comparative effectiveness of SDM with usual care.

Methods

We searched academic and grey literature databases, and other sources for primary randomised controlled trials (RCTs) published in English comparing SDM to usual care and conducted in primary and specialised care. We assessed the individual study risk of bias, and calculated the study-specific and pooled relative risks (RR) or standardised mean differences (SMD) [with 95% confidence intervals (CI)] to perform random-effects meta-analyses for SDM-related and patient outcomes.

Results

Four RCTs comparing SDM to usual care, involving 1760 men, were included. SDM improved knowledge (SMD 0.23, 95%CI 0.02 to 0.43; 2 RCTs), but was not different to usual care in reducing either patient participation in prostate-specific antigen (PSA) testing (RR 1.03, 95%CI 0.90 to 1.19; 2 RCTs) or decisional conflict (SMD -0.04, 95%CI -0.23 to 0.15; SMD -0.05, 95%CI -0.24 to 0.14; 2 RCTs). Individual trial estimates (46.7%) also suggest that SDM may reduce or neutralise physicians’ tendency for PSA screening, and may improve the accuracy of patients’ perception of lifetime-risks and men’s views towards screening. There was no evidence on the effects of SDM on health outcomes. The studies represent various interventions and outcomes and are prone to risk of bias.

Conclusions

There is currently insufficient evidence to support a clear association of SDM on patient- and SDM-related outcomes for decisions about PSA testing. Further research needs to assess the clinical effectiveness of SDM using well-defined SDM interventions and outcomes. It should address the absence of evidence, particularly on health outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4794-7) contains supplementary material, which is available to authorized users.

Prostate cancer screening with prostate-specific antigen (PSA) test: a systematic review and meta-analysis

OBJECTIVE

To investigate the efficacy and safety of prostate-specific antigen (PSA) testing to screen for prostate cancer.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Electronic search of Cochrane Central Register of Controlled Trials, Web of Science, Embase, Scopus, OpenGrey, LILACS, and Medline, and search of scientific meeting abstracts and trial registers to April 2018.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials comparing PSA screening with usual care in men without a diagnosis of prostate cancer.

DATA EXTRACTION

At least two reviewers screened studies, extracted data, and assessed the quality of eligible studies. A parallel guideline committee (BMJ Rapid Recommendation) provided input on the design and interpretation of the systematic review, including selection of outcomes important to patients. We used a random effects model to obtain pooled incidence rate ratios (IRR) and, when feasible, conducted subgroup analyses (defined a priori) based on age, frequency of screening, family history, ethnicity, and socioeconomic level, as well as a sensitivity analysis based on the risk of bias. The quality of the evidence was assessed with the GRADE approach.

RESULTS

Five randomised controlled trials, enrolling 721 718 men, were included. Studies varied with respect to screening frequency and intervals, PSA thresholds for biopsy, and risk of bias. When considering the whole body of evidence, screening probably has no effect on all-cause mortality (IRR 0.99, 95% CI 0.98 to 1.01; moderate certainty) and may have no effect on prostate-specific mortality (IRR 0.96, 0.85 to 1.08; low certainty). Sensitivity analysis of studies at lower risk of bias (n=1) also demonstrates that screening seems to have no effect on all-cause mortality (IRR 1.0, 0.98 to 1.02; moderate certainty) but may have a small effect on prostate-specific mortality (IRR 0.79, 0.69 to 0.91; moderate certainty). This corresponds to one less death from prostate cancer per 1000 men screened over 10 years. Direct comparative data on biopsy and treatment related complications from the included trials were limited. Using modelling, we estimated that for every 1000 men screened, approximately 1, 3, and 25 more men would be hospitalised for sepsis, require pads for urinary incontinence, and report erectile dysfunction, respectively.

CONCLUSIONS

At best, screening for prostate cancer leads to a small reduction in disease-specific mortality over 10 years but has does not affect overall mortality. Clinicians and patients considering PSA based screening need to weigh these benefits against the potential short and long term harms of screening, including complications from biopsies and subsequent treatment, as well as the risk of overdiagnosis and overtreatment.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42016042347.

Rastreamento populacional para o câncer de próstata: mais riscos que benefícios

Resumo Recentemente, inúmeras campanhas nacionais promovidas por hospitais, sociedades médicas e outras organizações têm estimulado o rastreamento do câncer de próstata, em consonância com iniciativas mundiais conhecidas como Novembro Azul. Essas campanhas aconselham a utilização do toque retal acompanhado da dosagem sérica do antígeno prostático específico em faixas etárias definidas. A motivação seria a detecção precoce da neoplasia, com redução de sua mortalidade e das complicações e impactos associados ao seu tratamento. A dosagem do PSA para fins de rastreamento é alvo de grande controvérsia, visto que a maioria dos tumores detectados pelo rastreamento é de evolução lenta e não interfeririam na sobrevida ou na qualidade de vida do paciente. O rastreamento de base populacional não é a indicação de inúmeras instituições estrangeiras e, no Brasil, o Instituto Nacional de Câncer também não recomenda à organização programas de rastreamento desse tipo. O artigo discute os riscos e benefícios associados a esse tipo de estratégia e reforça a preocupação com o uso inadequado e indiscriminado do rastreamento para o câncer de próstata.

Prostate cancer screening: what can we learn from randomised trials?

In this article, the principle of randomised trials are first described and then prostate cancer screening trials published to date are evaluated based on these principles. A summary of the randomised prostate cancer screening is provided. The conclusion that can be made from the results of the screening trials, as well as limitations of the evidence and open questions are outlined in the end.

Stopping screening, when and how?

Screening for prostate cancer (PC) is still controversial despite randomized trials has found that PC mortality is decreased. The major concern is the high rate of over-diagnosis and subsequent harms that may follow in many men who never would have had any symptoms during life-time if not screened. The high rate of over-diagnosis is driven by the large reservoir of small non-significant cancers that increases with age and found in more than half of men over 70 years, the low specificity of prostate specific antigen (PSA) but also by current "blind" biopsy technique that risk accidentally to hit these small non-significant cancers. The risk of over-diagnosis is increasing with age and the trade-off by screening men in high age is probably higher. At what age harms exceeds benefits is not established but modelling studies has demonstrated that after 65-70 years the quality adjusted life-years (QALYs) gained are decreasing but still on the positive side if screening is continued up to 75 years. A dilemma is that most PC deaths occur in men after the age 80 and the effect of screening seems not to last as long as was thought, already 10 years after termination of screening PC mortality has caught up in the screening arm to a level similar to that in the control group. In the European Randomised Study of Screening for Prostate Cancer (ERSPC) screening was terminated between 71 and 75 years and the first effect of screening on mortality was discernible after 7 years and has been relatively stable around 20% since 9 years after study start. It seems questionable from any standpoint to invite men for screening with an expected life length below 10 years, which is the expected life-length of an averaged 78-year-old man in 2018. However, the balance between harms and benefits specifically in the age 70-80 need more attention as also costs need. Permanent side-effects from (unnecessary) treatments and their impact on quality of life must be evaluated better and related to age and individual variations. In future better screening methods with more specific markers and introduction of imaging will hopefully decrease the present large risk of over-diagnosis in elderly men and thereby expand efficient screening to men in the age group >70 who actually is the high risk group of dying from PC.

PSA screening - for whom and when?

Reasons for and against screening of prostate cancer have been discussed widely over the last decade. In 2014, the European Randomized Trial for Screening of Prostate Cancer (ERSPC) has reported a relative reduction of the cancer-specific survival of 27% in participants who definitely followed the screening protocol. This relative advantage has proven to be stable from year 7 to year 13 after the beginning of screening. Still, the disadvantages of overdiagnosis and overtreatment are the downsides of a population-based screening approach. But given the overall advantage of screening, a risk-adapted prostate-specific antigen (PSA) screening using a baseline PSA value at ages 45-50 may significantly reduce the number needed to diagnose maintaining the benefits of screening. PROBASE is a randomized risk-adapted screening trial currently ongoing in Germany to answer this important question.

Prostate Cancer Screening

OBJECTIVE

To review the current state of prostate cancer screening and future directions.

DATA SOURCES

Nursing, medical and scientific literature related to prostate cancer screening, and national and international professional recommendations.

CONCLUSION

Prostate cancer screening has been a topic of robust discussion for a number of years. Research continues to examine novel options for prostate cancer screening to either replace or compliment the prostate specific antigen test, but require additional validation before they will be widely accepted into clinical practice.

IMPLICATIONS FOR NURSING PRACTICE

As new data emerges and professional organizations update their recommendations, it is important for oncology nurses to keep abreast of the latest developments to educate patients.

Screening Coverage Needed to Reduce Mortality from Prostate Cancer: A Living Systematic Review

INTRODUCTION

Screening for prostate cancer remains controversial because of conflicting results from the two major trials: The Prostate, Lung, Colorectal and Ovarian Cancer (PLCO) screening trial and the European Randomized Study of Screening for Prostate Cancer (ERSPC).

OBJECTIVE

Meta-analyze and meta-regress the available PSA screening trials.

METHODS

We performed a living systematic review and meta-regression of the reduction in prostate cancer mortality as a function of the duration of screening provided in each trial. We searched PubMed, Web of Science, the Cochrane Registry, and references lists from previous meta-analyses to identify randomized trials of PSA screening. We followed PRISMA guidelines and qualified strength of evidence with a GRADE Profile.

RESULTS

We found 6 trials, but excluded one that also screened with trans-rectal ultrasound. We considered each ERSPC center as a separate trial. When pooling together all 11 trials we found no significant benefit from screening; however, the heterogeneity was 28.2% (95% CI: 0% to 65%). Heterogeneity was explained by variations in the duration of serial screening (I2 0%; 95% CI: 0% to 52%). When we analyzed the subgroup of trials that added more than 3 years of screening (range 3.2 to 3.8) we found a significant benefit for screening with risk ratio 0.78 (95% CI 0.65-0.94; I2 = 0%; 95% CI: 0% to 69%) and a number needed to invite for screening of 1000. We downgraded the quality of evidence to moderate due to our retrospective identification of subgroups and limited data on control group screening.

CONCLUSIONS

Adequate duration of screening reduces mortality from prostate cancer. The benefit, while small, compares favorably with screening for other cancers. Our projections are limited by the moderate quality of evidence.

Men under the age of 55 years with screen detected prostate cancer do not have less significant disease compared to older men in a population of patients in Australia

Background

The American Urological Association (AUA) changed their Prostate-Specific Antigen (PSA) screening guidelines in 2013 to not recommend testing in men under 55 years of age without significant risk factors (such as a family history of prostate cancer or African ethnicity). The AUA argues that the rates of 'insignificant' prostate cancer (PC) in men under 55 are so high that the potential harms of PSA-testing in this population (over diagnosis and overtreatment) outweigh the benefits (early detection and treatment). Our study aims to identify and compare the rates of insignificant and high-risk PC in men diagnosed with PC ≤55 years and >55 years in two centres in Sydney, Australia.

Methods

Men with an abnormal screening PSA or DRE and diagnosed with PC by prostate biopsy were included in this study. A consecutive series of men were accrued from two major urology centres between the years 2006 and 2014. The analysis was divided into two parts, the first compared PC biopsy characteristics between men aged ≤55 years and those >55 years. The second analysis compared the prostatectomy pathological characteristics between the two groups. Differences were analysed by Chi squared and significance set at p < 0.05.

Results

A total of 598 prostate biopsies and 723 prostatectomy matched subjects were included. On prostate biopsies, 14.0 % of men ≤55 years and 11.9 % of men >55 years had insignificant PC (X² = 0.32, df = 1, p = 0.57), whilst 24.7 % of men ≤55 years and 25.1 % of men >55 years had high-risk PC (X² = 0.007, df = 1, p = 0.93). On prostatectomy specimens, 9.1 % of men ≤55 years and 6.5 % of men >55 years had insignificant PC (X² = 1.25, df = 1, p = 0.26), whilst 20.0 % of men ≤55 years and 24.0 % of men >55 years had high-risk PC (X² = 0.83, df = 1, p = 0.36).

Conclusion

We found no significant difference in the rates of insignificant and high-risk PC between men ≤55 years and >55 years, in either the prostate biopsies or prostatectomy specimens. Further trials need to be performed with comparable sample sizes and controlling of risk factors to assess the utility of PSA screening in younger men.

European Code against Cancer, 4th Edition: Cancer screening

In order to update the previous version of the European Code against Cancer and formulate evidence-based recommendations, a systematic search of the literature was performed according to the methodology agreed by the Code Working Groups. Based on the review, the 4th edition of the European Code against Cancer recommends: "Take part in organized cancer screening programmes for: Bowel cancer (men and women); Breast cancer (women); Cervical cancer (women)." Organized screening programs are preferable because they provide better conditions to ensure that the Guidelines for Quality Assurance in Screening are followed in order to achieve the greatest benefit with the least harm. Screening is recommended only for those cancers where a demonstrated life-saving effect substantially outweighs the potential harm of examining very large numbers of people who may otherwise never have, or suffer from, these cancers, and when an adequate quality of the screening is achieved. EU citizens are recommended to participate in cancer screening each time an invitation from the national or regional screening program is received and after having read the information materials provided and carefully considered the potential benefits and harms of screening. Screening programs in the European Union vary with respect to the age groups invited and to the interval between invitations, depending on each country's cancer burden, local resources, and the type of screening test used For colorectal cancer, most programs in the EU invite men and women starting at the age of 50-60 years, and from then on every 2 years if the screening test is the guaiac-based fecal occult blood test or fecal immunochemical test, or every 10 years or more if the screening test is flexible sigmoidoscopy or total colonoscopy. Most programs continue sending invitations to screening up to the age of 70-75 years. For breast cancer, most programs in the EU invite women starting at the age of 50 years, and not before the age of 40 years, and from then on every 2 years until the age of 70-75 years. For cervical cancer, if cytology (Pap) testing is used for screening, most programs in the EU invite women starting at the age of 25-30 years and from then on every 3 or 5 years. If human papillomavirus testing is used for screening, most women are invited starting at the age of 35 years (usually not before age 30 years) and from then on every 5 years or more. Irrespective of the test used, women continue participating in screening until the age of 60 or 65 years, and continue beyond this age unless the most recent test results are normal.

Nothing like data showing significant death reduction can better support prostate cancer screening

At 13 years of follow-up, the European Randomized Study of Screening for Prostate Cancer shows a 21% decrease in prostate cancer deaths in the prostate-specific antigen-screened group compared to control. This difference increases to 27% when non compliance is taken into account. The benefits of screening compared to control are higher at 28% (compared to 21%) when duration of follow-up ranges between 8 and 12 years. Such data obtained following an average rate of one screening performed once every 5.7 years in quite impressive and strongly supports the use of screening for a successful fight against a cancer which grows to an advanced and non curable stage without any specific sign or symptom.

Impact of Early Diagnosis of Prostate Cancer on Survival Outcomes

CONTEXT

The relationship between early detection of prostate cancer (PCa) and disease-specific mortality is still the subject of much debate.

OBJECTIVE

This review describes developments in PCa mortality rates and disease-stage shift on a population level. The main findings from the randomised screening trials are also discussed. Finally, we consider the expected consequences for the individual man interested in screening.

EVIDENCE ACQUISITION

The PubMed database was searched for trials of screening for PCa from inception through October 11, 2014. Supplementary information was collected by cross-referencing the reference lists.

EVIDENCE SYNTHESIS

Since the introduction of prostate-specific antigen testing, PCa incidence has risen, and a stage shift towards more favourable disease at diagnosis has been observed. PCa mortality rates are gradually decreasing. Although screening trials show conflicting results, the largest randomised trial of screening for PCa shows a 21% decrease in PCa-specific mortality. After correction for noncompliance and contamination, a risk reduction in PCa-specific mortality of up to 49% has been reported. The main side effect of screening is that some studies have estimated that approximately 50% of detected cases may represent overdiagnosis, which may be reduced by stopping screening in older men and using an individual risk-based approach.

CONCLUSIONS

To maximise the benefits while minimising the risk of overdiagnosis, future screening should follow an individual risk-based approach.

PATIENT SUMMARY

On a population level, the introduction of screening for prostate cancer (PCa) is associated with more men diagnosed but with more favourable disease. The largest screening study confirmed the reduction in death due to PCa. Individual risk estimation is important to best balance the benefits and potential harms of early detection.

Prostate-specific antigen-based prostate cancer screening: Past and future

Prostate-specific antigen-based prostate cancer screening remains a controversial topic. Up to now, there is worldwide consensus on the statement that the harms of population-based screening, mainly as a result of overdiagnosis (the detection of clinically insignificant tumors that would have never caused any symptoms), outweigh the benefits. However, worldwide opportunistic screening takes place on a wide scale. The European Randomized Study of Screening for Prostate Cancer showed a reduction in prostate cancer mortality through prostate-specific antigen based-screening. These population-based data need to be individualized in order to avoid screening in those who cannot benefit and start screening in those who will. For now, lacking a more optimal screening approach, screening should only be started after the process of shared decision-making. The focus of future research is the reduction of unnecessary testing and overdiagnosis by further research to better biomarkers and the value of the multiparametric magnetic resonance imaging, potentially combined in already existing prostate-specific antigen-based multivariate risk prediction models.

Patient-reported urinary incontinence and erectile dysfunction following radical prostatectomy: results from the European Prostate Centre Innsbruck

INTRODUCTION

Urinary and erectile functions were assessed by using self-administered validated questionnaires in patients undergoing radical prostatectomy.

MATERIALS AND METHODS

In a prospective observational study, a total of 253 consecutive patients diagnosed with clinically localised prostate cancer between 2008 and 2009 at the European Prostate Centre Innsbruck were included. Patient-reported outcomes were assessed before radical prostatectomy and 12 months postoperatively using the validated International Consultation on Incontinence Questionnaire (ICIQ) and the International Index of Erectile Function (IIEF). The Wilcoxon signed-rank test and Chi square statistics were used for analysis.

RESULTS

The study showed that before radical prostatectomy, urinary incontinence of various severity grades was reported in 18.8, postoperatively in 63.0% (p < 0.001) and erectile dysfunction of various degrees was reported in 39.6 at baseline compared to 80.1% 12 months postoperatively (p < 0.001).

CONCLUSIONS

This study suggests that radical prostatectomy is associated with a significantly increased risk of urinary incontinence and erectile dysfunction 12 months postoperatively.

Prostate Specific Antigen as a Tumor Marker in Prostate Cancer: Biochemical and Clinical Aspects

In this chapter the use of prostate specific antigen (PSA) as a tumor marker for prostate cancer is discussed. The chapter provides an overview of biological and clinical aspects of PSA. The main drawback of total PSA (tPSA) is its lack of specificity for prostate cancer which leads to unnecessary biopsies. Moreover, PSA-testing poses a risk of overdiagnosis and subsequent overtreatment. Many PSA-based markers have been developed to improve the performance characteristics of tPSA. As well as different molecular subforms of tPSA, such as proPSA (pPSA) and free PSA (fPSA), and PSA derived kinetics as PSA-velocity (PSAV) and PSA-doubling time (PSADT). The prostate health index (phi), PSA-density (PSAD) and the contribution of non PSA-based markers such as the urinary transcripts of PCA3 and TMPRSS-ERG fusion are also discussed. To enable further risk stratification tumor markers are often combined with clinical data (e.g. outcome of DRE) in so-called nomograms. Currently the role of magnetic resonance imaging (MRI) in the detection and staging of prostate cancer is being explored.

Application of the 2013 American Urological Association early detection of prostate cancer guideline: who will we miss?

PURPOSE

The American Urological Association (AUA) published new prostate cancer (CaP) screening guidelines in 2013. We apply the guidelines to a retrospective cohort to compare tumor characteristics of those no longer recommended for screening with those who remain screening candidates.

METHODS

We identified cases of screening detected CaP (stage cT1c) in the Surveillance Epidemiology and End Results database from October 2005 to December 2010. The 2013 AUA Guidelines were retrospectively applied to the cohort. Men were categorized into three groups for comparison based on whether or not they would now be recommended for CaP screening (Unscreened, Young Unscreened, and Screened). We compared clinical and pathological characteristics of CaP across study groups.

RESULTS

A total of 142,382 men were identified. Screening would no longer be recommended for 40,160. Those no longer recommended for screening had higher median PSA (6.4 vs. 5.8 ng/mL, p < 0.01), more Gleason 7 and ≥8 CaP on prostate biopsy (36.4 vs. 34.8 %, p < 0.001; 12.4 vs. 9.2 %, p < 0.001, respectively) and slightly more Gleason ≥8 CaP (9.0 vs. 7.5 %, p = 0.03), and T3 tumors (17.3 vs. 16.5 %, p = 0.01) at prostatectomy. Nodal and distant metastasis rates were clinically equivalent among men screened and unscreened. Subgroup analysis of young patients (40-54 years old) no longer recommended for screening identified intermediate or high-risk Gleason scores at prostatectomy 57.6 % of the time.

CONCLUSIONS

Features of CaP in men no longer recommended for routine screening are largely equivalent to if not worse than those in screened men.

[Early detection of prostate cancer: harm verified, benefit not verifiable]

The results of randomized studies on the early detection of prostate cancer and those of a systematic Cochrane review are compiled and interpreted. Some fundamental and inherent weaknesses of screening studies are pointed out and discussed. The meta-analysis of studies involving a total of 321,594 participants shows no reduction in prostate cancer mortality or all-cause mortality, but describes disadvantages such as unnecessary biopsies, overdiagnosis, and overtreatment. A relevant increase in overall mortality cannot be excluded. Even in future trials, the possible reduction of prostate cancer mortality or all-cause mortality by prostate cancer screening will not be detectable because of inherent methodological problems, e.g., an extremely high number of participants are needed. Furthermore, by nature, studies on the early detection of cancer last very long, such that the results are inevitably outdated at the end of the study. There is a risk that studies on the early detection of cancer suggest an advantage and at the same time overlook a relevant increase in overall mortality. Prostate cancer screening also ignores important WHO criteria for screening programs: There is evidence that early treatment of prostate cancer is not better than late treatment. There is no suitable or reliable test to identify the early stages of the disease. The benefit-risk ratio is not clearly favorable, and there is doubt whether the costs and the benefits are in an acceptable balance. There are valid reasons to advise against population-based prostate cancer screening.

The politics of prostate cancer screening

The controversial recent recommendation by the United States Preventive Services Task Force (USPSTF) against prostate-specific antigen (PSA) screening for early-stage prostate cancer has caused much debate. Whereas USPSTF recommendations against routine screening mammography in younger women resulted in fierce public outcry and eventual alteration in the language of the recommendation, the same public and political response has not been seen with PSA screening for prostate cancer. It is of paramount importance to ensure improved efficiency and transparency of the USPSTF recommendation process, and resolution of concerns with the current USPSTF recommendation against PSA screening for all ages.

A national survey of radiation oncologists and urologists on recommendations of prostate-specific antigen screening for prostate cancer

OBJECTIVE

To assess recommendations for prostate-specific antigen (PSA) screening in a national survey of radiation oncologists and urologists following the recent USA Preventive Services Task Force (USPSTF) grade D recommendation.

METHODS

A random sample of 1366 radiation oncologists and urologists were identified from the American Medical Association Physician Masterfile. From November 2011 to April 2012, a mail survey was sent to query PSA screening recommendations for men at average risk of prostate cancer for the following age groups: 40-49, 50-59, 60-69, 70-74, 75-79 and ≥80 years. Multivariable logistic regression was used to test for differences in PSA-based screening recommendations by physician characteristics.

RESULTS

Response rates were similar at 52% for radiation oncologists and urologists (P = 0.92). Overall, 51.5% of respondents recommended PSA-based screening for men aged 40-49 years, while nearly all endorsed it for those aged 50-74 years (96.1% for 50-59, 97.3% for 60-69, and 87.7% for 70-74 years). However, screening recommendations decreased to 43.9% and 12.8% for men aged 75-79 and ≥80 years, respectively. On multivariable analysis, urologists were more likely to recommend screening for men aged 40-49 (odds ratio [OR] 3.09; P < 0.001) and 50-59 years (OR 3.81; P = 0.01), but less likely for men aged 75-79 (OR 0.66; P = 0.01) and ≥80 years (OR 0.45; P = 0.002) compared with radiation oncologists.

CONCLUSION

While radiation oncologists and urologists recommended PSA screening for men aged 50-69 years, there was less agreement about screening for younger (40-49 years old) and older (≥70 years) men at average risk for prostate cancer.

Early detection of prostate cancer: European Association of Urology recommendation

BACKGROUND

The recommendations and the updated EAU guidelines consider early detection of PCa with the purpose of reducing PCa-related mortality and the development of advanced or metastatic disease.

OBJECTIVE

This paper presents the recommendations of the European Association of Urology (EAU) for early detection of prostate cancer (PCa) in men without evidence of PCa-related symptoms.

EVIDENCE ACQUISITION

The working panel conducted a systematic literature review and meta-analysis of prospective and retrospective clinical studies on baseline prostate-specific antigen (PSA) and early detection of PCa and on PCa screening published between 1990 and 2013 using Cochrane Reviews, Embase, and Medline search strategies.

EVIDENCE SYNTHESIS

The level of evidence and grade of recommendation were analysed according to the principles of evidence-based medicine. The current strategy of the EAU recommends that (1) early detection of PCa reduces PCa-related mortality; (2) early detection of PCa reduces the risk of being diagnosed and developing advanced and metastatic PCa; (3) a baseline serum PSA level should be obtained at 40-45 yr of age; (4) intervals for early detection of PCa should be adapted to the baseline PSA serum concentration; (5) early detection should be offered to men with a life expectancy ≥ 10 yr; and (6) in the future, multivariable clinical risk-prediction tools need to be integrated into the decision-making process.

CONCLUSIONS

A baseline serum PSA should be offered to all men 40-45 yr of age to initiate a risk-adapted follow-up approach with the purpose of reducing PCa mortality and the incidence of advanced and metastatic PCa. In the future, the development and application of multivariable risk-prediction tools will be necessary to prevent over diagnosis and over treatment.

Is prostate-specific antigen effective for population screening of prostate cancer? A systematic review

BACKGROUND

The effectiveness of prostate-specific antigen (PSA) for population screening has presented controversial results in large trials and prior reviews. We investigated the effectiveness of PSA population screening in a systematic review.

METHODS

The study was conducted using existing systematic reviews. We searched Ovid MEDLINE, Embase, Cochrane library, and the major Korean databases. The quality of the systematic reviews was assessed by two reviewers independently using AMSTAR. Randomized controlled trials were assessed using the risk of bias tool in the Cochrane group. Meta-analyses were conducted using Review Manager. The level of evidence of each outcome was assessed using GRADE.

RESULTS

Prostate-cancer-specific mortality was not reduced based on similar prior reviews (relative risk [RR] 0.93; 95% confidence interval [CI], 0.81-1.07, P=0.31). The detection rate of stage 1 prostate cancer was not greater, with a RR of 1.67 (95% CI, 0.95-2.94) and high heterogeneity. The detection rate of all cancer stages in the screening group was high, with a RR of 1.45 (95% CI, 1.13-1.85). No difference in all-cause mortality was observed between the screening and control groups (RR, 0.99; 95% CI, 0.98-1.01, P=0.50). Prostate-cancer-specific mortality, all-cause mortality, and diagnosis of prostate cancer at stages 3-4 showed moderate levels of evidence.

CONCLUSIONS

Differently from prior studies, our review included updated Norrköping data and assessed the sole effect of PSA testing for prostate cancer screening. PSA screening alone did not increase early stage prostate cancer detection and did not lower mortality.

PSA screening for prostate cancer: why so much controversy?

Since prostate cancer reaches the advanced and non curable stage in the absence of any specific symptom or sign, it seems reasonable to diagnose this cancer at an early and curable stage. Screening by prostate-specific antigen (PSA) has been the common technology used. The last follow-up of the first two prospective and randomized screening studies for prostate cancer, namely the Quebec and ERSPC (European Randomized Study of Screening for Prostate Cancer) clinical trials started in 1988 and 1991, respectively, have shown reductions of prostate cancer death of 62% (P<0.002) and 21% (P<0.001) (38% in the tenth and eleventh years of follow-up, P<0.003), respectively, while the PLCO (Prostate Lung Colorectal and Ovarian Cancer) screening trial reported no benefit. It has been estimated, however, that 85% of men in the planned 'non-screened' group of the US study have been screened. With such a serious flaw, the PLCO study does not have the statistical power to reach any valid conclusion. In the Quebec study, only 7.3% of men were screened in the control arm. The important benefit observed in the ERSPC study was achieved using a less than optimal 4-year PSA screening interval which misses a significant number of cancers while the Quebec study used the optimal 1-year interval. With proper information obtained from their physicians or otherwise using data collected only from the clinical trials having the required statistical power, men should be in a good position to decide about being or not being screened for prostate cancer.

Screening for prostate cancer

BACKGROUND

Any form of screening aims to reduce disease-specific and overall mortality, and to improve a person's future quality of life. Screening for prostate cancer has generated considerable debate within the medical and broader community, as demonstrated by the varying recommendations made by medical organizations and governed by national policies. To better inform individual patient decision-making and health policy decisions, we need to consider the entire body of data from randomised controlled trials (RCTs) on prostate cancer screening summarised in a systematic review. In 2006, our Cochrane review identified insufficient evidence to either support or refute the use of routine mass, selective, or opportunistic screening for prostate cancer. An update of the review in 2010 included three additional trials. Meta-analysis of the five studies included in the 2010 review concluded that screening did not significantly reduce prostate cancer-specific mortality. In the past two years, several updates to studies included in the 2010 review have been published thereby providing the rationale for this update of the 2010 systematic review.

OBJECTIVES

To determine whether screening for prostate cancer reduces prostate cancer-specific mortality or all-cause mortality and to assess its impact on quality of life and adverse events.

SEARCH METHODS

An updated search of electronic databases (PROSTATE register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CANCERLIT, and the NHS EED) was performed, in addition to handsearching of specific journals and bibliographies, in an effort to identify both published and unpublished trials.

SELECTION CRITERIA

All RCTs of screening versus no screening for prostate cancer were eligible for inclusion in this review.

DATA COLLECTION AND ANALYSIS

The original search (2006) identified 99 potentially relevant articles that were selected for full-text review. From these citations, two RCTs were identified as meeting the inclusion criteria. The search for the 2010 version of the review identified a further 106 potentially relevant articles, from which three new RCTs were included in the review. A total of 31 articles were retrieved for full-text examination based on the updated search in 2012. Updated data on three studies were included in this review. Data from the trials were independently extracted by two authors.

MAIN RESULTS

Five RCTs with a total of 341,342 participants were included in this review. All involved prostate-specific antigen (PSA) testing, with or without digital rectal examination (DRE), though the interval and threshold for further evaluation varied across trials. The age of participants ranged from 45 to 80 years and duration of follow-up from 7 to 20 years. Our meta-analysis of the five included studies indicated no statistically significant difference in prostate cancer-specific mortality between men randomised to the screening and control groups (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.86 to 1.17). The methodological quality of three of the studies was assessed as posing a high risk of bias. The European Randomized Study of Screening for Prostate Cancer (ERSPC) and the US Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial were assessed as posing a low risk of bias, but provided contradicting results. The ERSPC study reported a significant reduction in prostate cancer-specific mortality (RR 0.84, 95% CI 0.73 to 0.95), whilst the PLCO study concluded no significant benefit (RR 1.15, 95% CI 0.86 to 1.54). The ERSPC was the only study of the five included in this review that reported a significant reduction in prostate cancer-specific mortality, in a pre-specified subgroup of men aged 55 to 69 years of age. Sensitivity analysis for overall risk of bias indicated no significant difference in prostate cancer-specific mortality when referring to the meta analysis of only the ERSPC and PLCO trial data (RR 0.96, 95% CI 0.70 to 1.30). Subgroup analyses indicated that prostate cancer-specific mortality was not affected by the age at which participants were screened. Meta-analysis of four studies investigating all-cause mortality did not determine any significant differences between men randomised to screening or control (RR 1.00, 95% CI 0.96 to 1.03). A diagnosis of prostate cancer was significantly greater in men randomised to screening compared to those randomised to control (RR 1.30, 95% CI 1.02 to 1.65). Localised prostate cancer was more commonly diagnosed in men randomised to screening (RR 1.79, 95% CI 1.19 to 2.70), whilst the proportion of men diagnosed with advanced prostate cancer was significantly lower in the screening group compared to the men serving as controls (RR 0.80, 95% CI 0.73 to 0.87). Screening resulted in a range of harms that can be considered minor to major in severity and duration. Common minor harms from screening include bleeding, bruising and short-term anxiety. Common major harms include overdiagnosis and overtreatment, including infection, blood loss requiring transfusion, pneumonia, erectile dysfunction, and incontinence. Harms of screening included false-positive results for the PSA test and overdiagnosis (up to 50% in the ERSPC study). Adverse events associated with transrectal ultrasound (TRUS)-guided biopsies included infection, bleeding and pain. No deaths were attributed to any biopsy procedure. None of the studies provided detailed assessment of the effect of screening on quality of life or provided a comprehensive assessment of resource utilization associated with screening (although preliminary analyses were reported).

AUTHORS' CONCLUSIONS

Prostate cancer screening did not significantly decrease prostate cancer-specific mortality in a combined meta-analysis of five RCTs. Only one study (ERSPC) reported a 21% significant reduction of prostate cancer-specific mortality in a pre-specified subgroup of men aged 55 to 69 years. Pooled data currently demonstrates no significant reduction in prostate cancer-specific and overall mortality. Harms associated with PSA-based screening and subsequent diagnostic evaluations are frequent, and moderate in severity. Overdiagnosis and overtreatment are common and are associated with treatment-related harms. Men should be informed of this and the demonstrated adverse effects when they are deciding whether or not to undertake screening for prostate cancer. Any reduction in prostate cancer-specific mortality may take up to 10 years to accrue; therefore, men who have a life expectancy less than 10 to 15 years should be informed that screening for prostate cancer is unlikely to be beneficial. No studies examined the independent role of screening by DRE.

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.

Risk stratification in prostate cancer screening

Screening for prostate cancer is a controversial topic within the field of urology. The US Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial did not demonstrate any difference in prostate-cancer-related mortality rates between men screened annually rather than on an 'opportunistic' basis. However, in the world's largest trial to date--the European Randomised Study of Screening for Prostate Cancer--screening every 2-4 years was associated with a 21% reduction in prostate-cancer-related mortality rate after 11 years. Citing the uncertain ratio between potential harm and potential benefit, the US Preventive Services Task Force recently recommended against serum PSA screening. Although this ratio has yet to be elucidated, PSA testing--and early tumour detection--is undoubtedly beneficial for some individuals. Instead of adopting a 'one size fits all' approach, physicians are likely to perform personalized risk assessment to minimize the risk of negative consequences, such as anxiety, unnecessary testing and biopsies, overdiagnosis, and overtreatment. The PSA test needs to be combined with other predictive factors or be used in a more thoughtful way to identify men at risk of symptomatic or life-threatening cancer, without overdiagnosing indolent disease. A risk-adapted approach is needed, whereby PSA testing is tailored to individual risk.