The prostate cancer screening controversy has become even more complex with the publication of two longawaited studies and the release of two conflicting screening guidelines.1-4 For years, clinicians and patients have been anticipating the results of two large randomized controlled trials studying the outcomes of intensive prostatespecific antigen (PSA) screening on mortality and morbidity. Preliminary results of both studies have been published in the New England Journal of Medicine, but the results appear to have done little to clarify the balance of benefits and harms of widespread screening1,2 Table 1 shows a side-by-side summary of the two studies.
The Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial followed more than 76,000 US men for 7 years.1 The intervention group received annual PSA screening, and the control group received usual care that might include screening. The study found that prostate cancer was diagnosed in more men in the intervention group but that mortality rates were not statistically different between the groups. Thus, annual PSA screening did not reduce mortality.1
The European Randomized Study of Screening for Prostate Cancer (ERSPC) followed 182,000 European men for 9 years.2 As in the PLCO trial, the intervention group underwent regular PSA screening; in this study, however, the control group had no screening. The study reported that prostate cancer mortality was 20% lower in the screening group than in the control group; however, 1,410 men needed to be screened to prevent one death, and 48 men would need to be treated for prostate cancer to prevent one death.2
Shortly after these results were published in the spring of 2009, the American Urological Association published a controversial update to their Prostate-Specific Antigen Best Practice Statement; the update advised offering the PSA test to men aged 40 years to establish a baseline level to guide further testing decisions.3 This guidance is in direct contrast to the US Preventive Services Task Force (USPSTF) 2008 statement, which says that there is insufficient evidence to assess the balance of benefits and harms of PSA screening in men younger than 75 years.4 The USPSTF further recommends against PSA screening in men aged 75 years and older.