Prostate cancer screening

To the Editor: To make screening recommendations, including for PSA, one must consider an unbiased assessment of benefits, risks, and costs. Yet Sooriakumaran¹ fails to discuss current guidelines or the harms of screening, and falsely claims a mortality benefit. Gilligan’s accompanying editorial² fails to quantify those harms and briefly mentions the guidelines without giving the rationale to avoid screening. Both emphasize European Randomised Study of Screening for Prostate Cancer results showing a 20% relative risk reduction in disease-specific mortality.³

However, a better metric is absolute risk reduction (0.18% by our calculation), and the best metric is the absolute risk reduction for total mortality: none was noted.³ And readers of both articles would not know that for every prostate cancer death avoided, 240 men face an elevated PSA, 100 experience a cancer diagnosis, 80 of those get treatment, and 65 suffer significant harm.⁴

The “shared decision-making” Gilligan advocates may sound reasonable. But for PSA screening, where the risk-benefit analysis is unfavorable in most patients,⁴ shared decision-making is a chimera. If experts cannot fairly present the risks and benefits in the literature, much less agree on a strategy, how can lay people make an informed decision? “Punting” the decision to patients risks worsening their health outcomes at high costs, and may have profound implications for those who are unnecessarily harmed by their own decisions.⁵

Screening should be advised only if benefits clearly outweigh the risks. Sooriakumaran’s omission of risks and guidelines should have been addressed in Gilligan’s editorial. Together, the articles present a biased analysis of PSA screening that can cause patient harm, and the Journal should have published an article providing the case against screening.

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