Is It Necessary to Detect All Prostate Cancers in Men with Serum PSA Levels <3.0ng/ml? A Comparison of Biopsy Results of PCPT and Outcome-Related Information from ERSPC

Overview of tissue kallikrein and kallikrein-related peptidases in breast cancer

The kallikrein family comprises tissue kallikrein and 14 kallikrein-related peptidases (KLKs) recognized as a subgroup of secreted trypsin- or chymotrypsin-like serine proteases. KLKs are expressed in many cellular types where they regulate important physiological activities such as semen liquefaction, immune response, neural development, blood pressure, skin desquamation and tooth enamel formation. Tissue kallikrein, the oldest member and kinin-releasing enzyme, and KLK3/PSA, a tumor biomarker for prostate cancer are the most prominent components of the family. Additionally, other KLKs have shown an abnormal expression in neoplasia, particularly in breast cancer. Thus, increased levels of some KLKs may increase extracellular matrix degradation, invasion and metastasis; other KLKs modulate cell growth, survival and angiogenesis. On the contrary, KLKs can also inhibit angiogenesis and produce tumor suppression. However, there is a lack of knowledge on how KLKs are regulated in tumor microenvironment by molecules present at the site, namely cytokines, inflammatory mediators and growth factors. Little is known about the signaling pathways that control expression/secretion of KLKs in breast cancer, and further how activation of PAR receptors may contribute to functional activity in neoplasia. A better understanding of these molecular events will allow us to consider KLKs as relevant therapeutic targets for breast cancer.

Economic evaluation of the introduction of the Prostate Health Index as a rule-out test to avoid unnecessary biopsies in men with prostate specific antigen levels of 4-10 in Hong Kong

A recent study showed that the Prostate Health Index may avoid unnecessary biopsies in men with prostate specific antigen 4-10ng/ml and normal digital rectal examination in the diagnosis of prostate cancer in Hong Kong. This study aimed to conduct an economic evaluation of the impact of adopting this commercially-available test in the Hong Kong public health service to determine whether further research is justified. A cost-consequence analysis was undertaken comparing the current diagnostic pathway with a proposed diagnostic pathway using the Prostate Health Index. Data for the model was taken from a prospective cohort study recruited at a single-institution and micro-costing studies. Using a cut off PHI score of 35 to avoid biopsy would cost HK$3,000 and save HK$7,988 per patient in biopsy costs and HK$511 from a reduction in biopsy-related adverse events. The net cost impact of the change was estimated to be HK$5,500 under base case assumptions. At the base case sensitivity and specificity for all grades of cancer (61.3% and 77.5% respectively) all grade cancer could be missed in 4.22% of the population and high grade cancer in 0.53%. The introduction of the prostate health index into the diagnostic pathway for prostate cancer in Hong Kong has the potential to reduce biopsies, biopsy costs and biopsy-related adverse events. Policy makers should consider the clinical and economic impact of this proposal.

Effect of Age, Family History of Prostate Cancer, Prostate Enlargement and Seasonality on PSA Levels in a Contemporary Cohort of Healthy Italian Subjects

We assessed the joint effect of age at enrolment, age at follow-up, family history of prostate cancer, prostate enlargement and seasonality on prostate-specific antigen (PSA) estimated through log-normal mixed-effects modeling in an Italian cohort of healthy, 45- to 65-year-old subjects over a 4-year period. The median ratio was used as the measure of effect. Median and mean baseline PSA were 0.78 (interquartile range: 0.41–1.50) and 1.27 (95% CI: 1.19–1.35) ng/mL, respectively. A similar median annual increase of 5.7% (95% CI: 4.8%-6.5%) was found for age at enrolment and age at follow-up. Individuals with moderate to severe prostate enlargement had a median PSA ratio of 1.040 (95% CI: 0.919–1.176) and 1.318 (95% CI: 1.128–1.539), respectively. Median ratios of 1.200 (95% CI: 0.026–1.404) and 1.300 (95% CI: 0.915–1.845), respectively, were computed for subjects with only one or more than one prostate-cancer-affected relatives. Regarding seasonality, the highest value was shown in summertime, the lowest in wintertime, and the resulting median ratio was 1.280 (95% CI: 1.117–1.468). Irrespective of age, baseline PSA was in most cases about 1.00 ng/mL with a yearly median variation of about 5% over a 4-year period. Indeed, prostate enlargement, prostate cancer family history and seasonality showed a remarkable impact on PSA measurement. This should be considered when counseling patients with a PSA history.

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.

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.

Kallikrein-related peptidase 4 gene (KLK4) in prostate tumors: quantitative expression analysis and evaluation of its clinical significance

BACKGROUND

Recently accumulating evidences underline the central role of the kallikrein-related peptidases family (KLKs) in prostate cancer (PCa) development and progression. The KLK4 is a prostate highly expressed gene under the transcriptional control of androgens, encoding for the KLK4 extracellular serine protease. The aim of this study is to investigate the expression status of KLK4 in PCa patients in order to reveal its utility in PCa establishment and clinical management.

METHODS

Prostatic tissue specimens were obtained from 60 PCa and 59 benign prostate hyperplasia (BPH) randomly chosen patients. Using a developed quantitative real-time RT-PCR method, KLK4 expression levels were determined in the specimens of the two patients' cohorts. Advance biostatistical analysis was completed to explore the clinical value of KLK4 expression in PCa and BPH patients.

RESULTS

PCa patients presented a statistically significant (P = 0.002) elevation, more than threefold, of the KLK4 transcripts compared to BPH ones. The KLK4 expression levels were also positive correlated with PCa patients' stage (P = 0.031) and preoperative prostate-specific antigen (PSA) serum concentrations (P < 0.001). ROC curve and logistic regression analysis revealed the significant (P = 0.002) and the independent (P = 0.044) clinical value of the KLK4 expression for the discrimination of PCa from BPH patients.

CONCLUSIONS

The KLK4 expression analysis reveals its up-regulation in PCa cells, which is significantly associated with the advanced stages of the disease and the patients' preoperative PSA serum levels. KLK4 quantification serves as an independent biomarker for the discrimination between the malignant and the benign nature of prostate tumors.

Screening for prostate cancer: have we resolved the controversy?

PURPOSE OF REVIEW

Prostate cancer (PCa) screening has long been a source of controversy. In this review, we discuss the interim results of the European Randomized Study of Screening for Prostate Cancer (ERSPC) and the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial. Implications of these studies will also be underlined.

RECENT FINDINGS

With systematic prostate-specific antigen-based screening, the ERSPC reported a statistically significant PCa-specific mortality reduction of 20% favouring screening in the intention-to-treat analysis and 31% in the secondary analysis. In contrast, the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial showed no mortality reduction. On the basis of critical appraisal of the study design and methods, it is justified to rely on the results of the ERSPC, as the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial is rather a comparison between a screening group and a less screened group.

SUMMARY

Despite the effects demonstrated by the ERSPC, there is currently insufficient evidence to introduce a population-based screening programme. The studies evaluating quality of life and cost-efficiency need to be completed with the highest urgency and their results should be considered together with more mature data from the ERSPC to reach an effective implementation of screening on PCa. Meanwhile, we have to improve the screening test, screening protocol and further develop an accurate individualized risk assessment to decrease the rates of overdiagnosis and overtreatment, while the mortality reduction and the detection of clinically relevant PCa should be maintained.

Chemoprevention of prostate cancer

Over the past two decades, many more men are diagnosed with prostate cancer then die of the disease. This increase in diagnosis has led to aggressive treatment of indolent disease in many individuals and has been the impetus for finding a means of reducing the risk of prostate cancer. In the past decade, there have been eight large trials of prostate cancer risk reduction using dietary supplements, 5α-reductase inhibitors, or anti-estrogens. The only two trials which have demonstrated efficacy are those involving 5α-reductase inhibitors: the PCPT (finasteride) and REDUCE (dutasteride). This review examines prostate cancer risk reduction, with emphasis on conclusions that can be drawn from these two landmark studies.

A panel of kallikrein marker predicts prostate cancer in a large, population-based cohort followed for 15 years without screening

BACKGROUND

Prostate-specific antigen (PSA) has modest specificity for prostate cancer. A panel of four kallikrein markers (total PSA, free PSA, intact PSA, and kallikrein-related peptidase 2) is a highly accurate predictor of biopsy outcome. The clinical significance of biopsy-detectable cancers in men classified as low-risk by this panel remains unclear.

METHODS

The Malmö Diet and Cancer study is a population-based cohort of 11,063 Swedish men aged 45 to 73 providing a blood sample at baseline during 1991-1996. The Swedish Cancer Registry was used to identify 943 men diagnosed with prostate cancer by December 31, 2006. PSA testing was low. We assessed the predictive accuracy of our published statistical model to predict subsequent prostate cancer diagnosis in men with a total PSA level of 3.0 ng/mL or more at baseline.

RESULTS

Compared with total PSA and age, the full kallikrein panel enhanced the predictive accuracy for clinically diagnosed prostate cancer (concordance index 0.65 vs. 0.75; P < 0.001). For every 1,000 men with a total PSA level of 3 ng/mL or more at baseline, the model would classify as high-risk 131 of 152 (86%) of the cancer cases diagnosed clinically within 5 years; 421 men would be classified as low-risk by the panel and recommended against biopsy. Of these, only 2 would be diagnosed with advanced prostate cancer (clinical T3-T4 or metastases) within 5 years.

CONCLUSIONS

Men with a PSA level of 3 ng/mL or more but defined as low-risk by the panel of four kallikrein markers are unlikely to develop incurable prostate cancer.

IMPACT

Use of the panel to determine referral to biopsy could substantially reduce the number of unnecessary prostate biopsies.

The relationship between prostate-specific antigen and prostate cancer risk: the Prostate Biopsy Collaborative Group

PURPOSE

The relationship between prostate-specific antigen (PSA) level and prostate cancer risk remains subject to fundamental disagreements. We hypothesized that the risk of prostate cancer on biopsy for a given PSA level is affected by identifiable characteristics of the cohort under study.

EXPERIMENTAL DESIGN

We used data from five European and three U.S. cohorts of men undergoing biopsy for prostate cancer; six were population-based studies and two were clinical cohorts. The association between PSA and prostate cancer was calculated separately for each cohort using locally weighted scatterplot smoothing.

RESULTS

The final data set included 25,772 biopsies and 8,503 cancers. There were gross disparities between cohorts with respect to both the prostate cancer risk at a given PSA level and the shape of the risk curve. These disparities were associated with identifiable differences between cohorts: for a given PSA level, a greater number of biopsy cores increased the risk of cancer (odds ratio for >6- versus 6-core biopsy, 1.35; 95% confidence interval, 1.18-1.54; P < 0.0005); recent screening led to a smaller increase in risk per unit change in PSA (P = 0.001 for interaction term) and U.S. cohorts had higher risk than the European cohorts (2.14; 95% confidence interval, 1.99-2.30; P < 0.0005).

CONCLUSIONS

Our results suggest that the relationship between PSA and risk of a positive prostate biopsy varies, both in terms of the probability of prostate cancer at a given PSA value and the shape of the risk curve. This poses challenges to the use of PSA-driven algorithms to determine whether biopsy is indicated.

Finasteride to prevent prostate cancer: should all men or only a high-risk subgroup be treated?

PURPOSE Finasteride has been shown to reduce the incidence of prostate cancer. Yet the use of finasteride remains low, likely because of the risk of adverse effects. We sought to determine whether prostate-specific antigen (PSA) levels could identify a high-risk subgroup for which the benefits of finasteride treatment outweigh the potential harms. PATIENTS AND METHODS Raw data from the Prostate Cancer Prevention Trial were used to model chemopreventive treatment strategies: treat all men, treat no men, or treat a high-risk subgroup based on PSA level. We weighted the benefits (reduction in cancer rate) and harms (treatment rate) of each strategy using numbers-needed-to-treat thresholds-the maximum number of men a clinician would treat with finasteride to prevent one cancer. Results Of 9,058 men, 1,957 were diagnosed with prostate cancer during the 7-year study. For the end point of all cancers, including both for-cause and end-of-study biopsies, the optimal strategy is to treat all or nearly all men. To reduce risk of cancers detected through routine care, treating men with PSA > 1.3 or > 2 ng/mL is optimal. For example, treating only men with PSA > 2 ng/mL reduced the treatment rate by 83% and resulted in a cancer rate only 1.1% higher than treating all men. CONCLUSION Clinicians wishing to reduce the risk of any biopsy-detectable prostate cancer should recommend finasteride to all men. Clinicians who believe that it is unnecessary to prevent all cancers, but that preventing those readily detectable by screening would be desirable, would be best off recommending finasteride only to a high-risk subgroup.

Characteristics of prostate cancers found in specimens removed by radical cystoprostatectomy for bladder cancer and their relationship with serum prostate-specific antigen level

Prostate cancer mass screening using serum prostate-specific antigen (PSA) has been conducted widely in the world. However, little is known about the true prevalence of prostate cancer in the 'normal' PSA range (4.0 ng/mL or less). The aim of the present study was to elucidate the clinicopathological features of prostate cancer occurring in men with a wide range of PSA levels. The study comprised 349 male patients who underwent radical cystoprostatectomy for bladder cancer. Patients who had had treatment for known prostate cancer were excluded. Tissue specimens were reviewed microscopically. Ninety-one patients (26.1%) were found to have prostate cancer, and 68 (74.7%) of these 91 cancers were considered to be clinically significant. Both increasing patient age and PSA level were significantly correlated with an increased incidence of both all and significant prostate cancers. Sixty-five (21.9%) among 297 patients with PSA < 4.0 ng/mL had prostate cancer, and 45 (69.2%) of the 65 cancers were significant cancers. Eighteen patients had prostate cancers 0.5 mL or more in volume. Among the 18 patients, the PSA level was 4 ng/mL or more in 11, and 3 ng/mL or more in 15. Our study shows that prostate cancer is a common finding in radical cystoprostatectomy specimens excised because of bladder cancers, and a significant proportion of these cancers are clinically significant. PSA still appears to be a useful screening tool for detecting prostate cancers with significant volume.

Review of diagnostic markers for prostate cancer

This review concentrates mainly on currently available markers for prostate cancer and cannot cover the multiple marker substances which are now in experimental and clinical development. Prostate-specific antigen (PSA) is still the main diagnostic tool despite its serious limitations, which will be addressed. Studies of new diagnostic markers and also most studies of PSA are subject to attribution or assignment bias, which limits the accuracy of the resulting information. Usually a more or less arbitrarily chosen cut-off value is used as a "gold standard" to determine the indication for the decisive test, a prostatic biopsy, and the assumption is made that no cancers are present below that cut-off value. This assumption has been proved wrong by findings in the control arm of the Prostate Cancer Prevention Trial (PCPT), where more than 5,000 men were biopsied independent of their PSA status. As an example: a PSA cut-off value of4.0 ng/ml, a commonly used biopsy indicator, missed about 75% of all biopsy-detectable cancers. On the other hand, sextant biopsies in all men led to a detection rate of 21.9%, evidence of the diagnosis of many cases in men who otherwise would never have had any clinical signs of prostate cancer (overdiagnosis). The only way out of this dilemma is a better understanding of the natural history of those cases with low PSA values that would not be considered suspicious with the use of currently available risk indicator nomograms. The European Randomised Study of Screening for Prostate Cancer (ERSPC) offers such an opportunity. Results are summarised in this chapter. Evidence is provided that men diagnosed in the low PSA ranges (< 3.0 ng/ml) usually present with more favourable cancers which, when identified, are often eligible for active surveillance after application of the appropriate nomogram. In addition, the data in the setting of the ERSPC study show that biopsy in such men can safely be delayed until PSA rises to above a cut-off value of 3.0 ng/ml. The limitations of PSA discussed herein clearly point to the need to find better diagnostic and prognostic markers for prostate cancer.

Clinical Impact of New Prostate-Specific Antigen WHO Standardization on Biopsy Rates and Cancer Detection

Background: Clinicians may be unaware that replacement of the historical total prostate-specific antigen (tPSA) standard with the WHO 96/670 international standard leads to difficulties in interpreting tPSA results. Our aim was to investigate the relationship between the Hybritech and WHO calibrations of the Beckman Coulter tPSA assay, and to assess the impact on prostate cancer (PCa) detection.

Methods: tPSA concentrations were measured in 106 serum samples with both Hybritech and WHO calibrations. The established relationships were used for an in silico experiment with a cohort of 5865 men. Differences in prostate biopsy rates, PCa detection, and characteristics of missed cancers were calculated at biopsy thresholds of 3.0 and 4.0 μg/L.

Results: A linear relationship was observed between the 2 calibrations, with a 20.3% decrease in tPSA values with the WHO standard compared with the Hybritech calibration. Applying the WHO calibration to the cohort of 5865 men yielded a 20% or 19% decrease in prostate biopsies and a 19% or 20% decrease in detected cancers compared with the Hybritech calibration, at a cutoff for biopsy of 3.0 or 4.0 μg/L, respectively. The decrease in detected cancers declined to 9% or 11% if an abnormal result in a digital rectal examination or a transrectal ultrasound evaluation was used as trigger for prostate biopsy (cutoff of 3.0 or 4.0 μg/L, respectively).

Conclusions: Application of the WHO standard for tPSA assays with commonly used tPSA thresholds leads to a significant decrease in PCa detection. Careful assessment of the relationship between the WHO standard and the thresholds used for prostate biopsy is hence necessary.

Screening for prostate cancer

BACKGROUND

Any form of screening aims to reduce mortality and increase a person's quality of life. Screening for prostate cancer has generated considerable debate within the medical community, as demonstrated by the varying recommendations made by medical organizations and governed by national policies. Much of this debate is due to the limited availability of high quality research and the influence of false-positive or false-negative results generated by use of the diagnostic techniques such as the digital rectal examination (DRE) and prostate specific antigen (PSA) blood test.

OBJECTIVES

To determine whether screening for prostate cancer reduces prostate cancer mortality and has an impact on quality of life.

SEARCH STRATEGY

Electronic databases (PROSTATE register, CENTRAL the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CANCERLIT and the NHS EED) were searched electronically in addition to hand searching of specific journals and bibliographies in an effort to identify both published and unpublished trials.

SELECTION CRITERIA

All randomised controlled trials of screening versus no screening or routine care for prostate cancer were eligible for inclusion in this review.

DATA COLLECTION AND ANALYSIS

The search identified 99 potentially relevant articles that were selected for full text review. From these 99 citations, two randomised controlled trials were identified as meeting the review's inclusion criteria. Data from the trials were independently extracted by two authors.

MAIN RESULTS

Two randomised controlled trials with a total of 55,512 participants were included; however, both trials had methodological weaknesses. Re-analysis using intention-to-screen and meta-analysis of results from the two randomised controlled trials indicated no statistically significant difference in prostate cancer mortality between men randomised for prostate cancer screening and controls (RR 1.01, 95% CI: 0.80-1.29). Neither study assessed the effect of prostate cancer screening on quality of life, all-cause mortality or cost effectiveness.

AUTHORS' CONCLUSIONS

Given that only two randomised controlled trials were included, and the high risk of bias of both trials, there is insufficient evidence to either support or refute the routine use of mass, selective or opportunistic screening compared to no screening for reducing prostate cancer mortality. Currently, no robust evidence from randomised controlled trials is available regarding the impact of screening on quality of life, harms of screening, or its economic value. Results from two ongoing large scale multicentre randomised controlled trials that will be available in the next several years are required to make evidence-based decisions regarding prostate cancer screening.