Platinum Priority – Prostate Cancer – Editor's ChoiceEditorial by Gunnar Steineck, Olof Akre and Anna Bill-Axelson on pp. 52–53 of this issueA 16-yr Follow-up of the European Randomized study of Screening for Prostate Cancer☆
Introduction
The European Randomized study of Screening for Prostate Cancer (ERSPC) was initiated in 1993, with the primary aim to investigate the effect of regular prostate-specific antigen (PSA) screening on prostate cancer (PCa) mortality. Findings were previously reported on three occasions, as prespecified in the study protocol at 9, 11, and 13 yr of follow-up [1], [2], [3]. The latest report (2014) showed that PSA screening increased PCa incidence 1.6-fold and the relative reduction in PCa mortality was 21% at 13 yr of follow-up [3]. This is the 16-yr main endpoint follow-up in order to quantify the long-term harms and benefits of screening. Secondary aims were to investigate how variations in screening attendance and duration of screening (one test only vs repeated testing) affected PCa mortality and whether this could explain the observed variations in outcome between different screening trials as well as between different ERSPC centres [3], [4].
Section snippets
Study design and participants
The ERSPC, described previously [1], [2], [3], is a multicentre randomised screening trial for PCa in eight European countries (Fig. 1). It started in Belgium and the Netherlands (1993), and the last country to join was France in 2003. Minor variations in screening protocols between centres were accepted, but compulsory criteria for participation were defined [5], including PSA as the primary screening test, followed by systematic prostate biopsies for men with elevated PSA; a core age group of
Primary analyses
A total of 182 160 men were randomised, of whom 162 389 were part of the core age group of men 55–69 yr old. Figure 1 shows the trial profile. Men randomised to the screening arm were screened on average 1.94 times (2.3 times in screening attendees), and of those participating, 28% were screen positive at least once (Table 1). Median follow-up (excluding France; from randomisation to a minimum of 16 yr, December 31, 2014, and the date of death) was 15.5 yr and median follow-up from diagnosis to PCa
Discussion
This ERSPC update with 3 additional years of follow-up shows that the absolute reduction in PCa mortality still increases with longer duration of follow-up, while the relative risk reduction remains unchanged at 20% since the initial report based on 8.8 yr of follow-up [1], [2], [3]. PCa incidence in the control group is gradually catching up with the screening arm, but at 16 yr, a 41% excess incidence remains in the screening arm. Results illustrate that both incidence and mortality differences
Conclusions
This 16-yr report from ERSPC shows that the absolute effect of screening on PCa mortality increases with longer follow-up. The excess PCa incidence among screened men is decreasing but is still rather high. The PCa mortality reduction seems to be related to the duration of screening, and a one-time screening test is suggested to have little or no effect on PCa mortality due to a prevalence pool of more advanced disease in which treatment is unlikely to provide major benefits.
Author
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