Specific features of the Italian section of the ERSPC

PSA Use and Incidence of Prostate Biopsy in the Tuscany Region: Is Opportunistic Screening Discounting Biopsy in Subjects with PSA Elevation?

Aims and Background

To assess PSA use in the general population and estimate biopsy rate subsequent to opportunistic screening.

Methods and Study Design

We report on PSA testing and related prostate biopsy frequency in the Tuscany Region during 2004–2005 to establish current patterns of care. We used population data sources to survey PSA testing and biopsy and estimated expected PSA values and expected recommended biopsies (≥PSA 4 ng/ml) from the ongoing Florence arm of the European Study of Screening for Prostate Cancer (ERSPC).

Results

PSA testing was common for both years and across age groups, increasing with age and peaking at 70–74 years (37.6% in 2004, 41.9% in 2005) and increasing over the 2 years. PSA use in the 55–69 years cohort (screening age in ERSPC) was 28.3% in 2004 and 30.4% in 2005. Repeat PSA testing was also common and repeat PSA probability increased with age, peaking at age 70–74 (60.9%); repeat PSA testing at age 55–69 was 53.7%. Overall, 1.3% and 1.2% of men had a biopsy following PSA testing in 2004 and 2005. Observed/expected biopsy incidence was 14.3% in 2004 and 13.2% in 2005. ERSPC compliance to recommended biopsy was 77% or 60% at first or repeat screening.

Conclusions

A discordance was identified between high PSA testing prevalence and low prostate biopsy rate. Based on projections from the ERSPC, this indicates a much lower observed biopsy rate than expected in organized screening. Although the implications of this are difficult to quantify in the absence of evidence on screening efficacy, it suggests inefficient practice.

Characteristics of men responding to an invitation to undergo testing for prostate cancer as part of a randomised trial

BACKGROUND

Sociodemographic characteristics are associated with participating in cancer screening and trials. We compared the characteristics of those responding with those not responding to a single invitation for prostate-specific antigen (PSA) testing for prostate cancer as part of the Cluster randomised triAl of PSA testing for Prostate cancer (CAP).

METHODS

Age, rurality and deprivation among 197,763 men from 271 cluster-randomised primary care centres in the UK were compared between those responding (n = 90,300) and those not responding (n = 100,953) to a prostate cancer testing invitation.

RESULTS

There was little difference in age between responders and nonresponders. Responders were slightly more likely to come from urban rather than rural areas and were slightly less deprived than those who did not respond.

CONCLUSION

These data indicate similarities in age and only minor differences in deprivation and urban location between responders and nonresponders. These differences were smaller, but in the same direction as those observed in other screening trials.

TRIAL REGISTRATION

ISRCTN92187251 . Registered on 29 November 2004.

Excess all-cause mortality in the evaluation of a screening trial to account for selective participation

OBJECTIVE

In addition to disease-specific mortality, a randomized controlled cancer screening trial may be evaluated in terms of excess mortality, in which case no patient-specific information on causes of death is needed. We studied the effect of not accounting for attendance on the calculated excess mortality in a prostate cancer screening trial.

METHODS

The numerator of the excess mortality rate related to prostate cancer diagnoses in each study arm equals the excess number of deaths observed in the cancer patients. The estimation of the expected number of deaths in the absence of the prostate cancer diagnoses has to account for the self-selection of those participating in the trial, particularly if the proportion of non-participants is substantial.

SETTING

The European prostate cancer screening trial (ERSPC).

RESULTS

In the screening arm, non-attendees had roughly twice the mortality rate of attendees. Approximately twice as many cancers were detected in the screening arm compared with the control arm, primarily in attendees. Unless attendance is properly accounted for, the expected mortality of prostate cancer patients in the screening arm is overestimated by 0.9-3.6 deaths per 1000 person-years.

CONCLUSIONS

Attendees have a lower all-cause mortality rate (are healthier) and a higher probability of a prostate cancer diagnosis than non-attendees and the men randomized to the control arm. If attendance is not accounted for, the excess mortality and the between-arm excess mortality rate ratio are underestimated and screening is considered more effective than it actually is. These effects may be sizeable, notably if non-attendance is common. Correcting for attendance status is important in the calculation of the excess mortality rate in prostate cancer patients that can be used in conjunction with a disease-specific mortality analysis in a randomized controlled cancer screening trial.

The implementation of screening for prostate cancer

The objective of this study was to determine whether screening for prostate cancer (PC) reduces PC mortality and, if so, whether the required criteria to be introduced as a population-based screening program are satisfied. A literature review was conducted through electronic scientific databases. The screening tests, that is, PSA and digital rectal examination, have limited sensitivity and specificity for detecting PC; screening produces a beneficial stage shift and reduces PC mortality. Nevertheless, PC screening causes a large increase in the cumulative incidence, and the understanding of the economic cost and quality-of-life parameters are limited. PC screening cannot be justified yet in the context of a public health policy.