Platinum Priority – Prostate CancerEditorial by Allison S. Glass, Matthew R. Cooperberg and Peter R. Carroll on pp. 753–755 of this issueScreening for Prostate Cancer Decreases the Risk of Developing Metastatic Disease: Findings from the European Randomized Study of Screening for Prostate Cancer (ERSPC)☆
Introduction
Screening for prostate cancer (PCa) remains controversial, even after the European Randomized Study of Screening for Prostate Cancer (ERSPC) [1], [2] reported a 21% relative reduction of deaths from PCa at 11 yr of follow-up and the Gothenburg (Sweden) trial, one of the ERSPC centers, showed 44% reduction at 14 yr [3]. The main reason for controversy concerns the harms associated with PCa screening, such as the high risk of overdiagnosis and overtreatment [4].
The occurrence of metastatic disease is a very important contributor to the suffering caused by PCa. Its prevention or delay is a legitimate secondary end point of screening. Earlier studies have reported that early diagnosis by prostate-specific antigen (PSA) testing results in a reduction of the number of men with metastatic disease [5], [6], [7]. The ERSPC study has shown a 41% decrease of metastatic disease in the screening arm at the time of diagnosis [1]; however, progression to metastatic disease during follow-up after initial treatment that was not evaluated in the ERSPC study [1] should also be influenced by screening.
The goal of this paper is to compare the incidence of metastatic disease, not only at diagnosis but also during subsequent follow-up, in the screening and control arms of four major centers of the ERSPC study group.
Section snippets
Materials and methods
The ERSPC is a randomized trial comparing an intervention arm of men to whom regular PSA screening is offered with a control arm to which such screening is not offered. Details of the methodology have been described previously for all centers in the ERSPC study [1] and for the Gothenburg trial by Hugosson et al. [3]. In all centers, known cases of PCa were excluded before randomization. The Swedish center utilized a 2-yr screening interval, whereas a 4-yr interval was applied at the other
Results
The study population is shown in Figure 1, which also shows the part of the total ERSPC population that is included in the present report. In addition, absolute numbers of participants, cancers and M+ cases diagnosed, and deaths per arm are shown. The numbers of participants in the screening and control arms, the numbers of men with M+ disease per center and per study arm, and the relative risks of M+ at diagnosis and during follow-up are specified in Table 1. The follow-up periods differed
Discussion
Our results show an absolute risk reduction of 3 M+ PCa cases per 1000 men, corresponding to a relative risk reduction of 30% (p = 0.001) in favor of screening. This reduction in M+ disease must be balanced against the downside of screening, mainly the rate of overdiagnosis in the screening arm, estimated at ≥50% in the setting of the ERSPC [4]; in the current analysis, a potential rate of overdiagnosis of 55.6% was shown. This report is next to that of Kilpeläinen et al. [10], which is limited
Conclusions
Our study shows relative reductions of 30% and 42% in M+ disease by screening for the whole population and for men who are screened, respectively, after 12 yr of follow-up. This benefit must be balanced against potential harms of screening.
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