Elsevier

The Lancet

Volume 361, Issue 9363, 29 March 2003, Pages 1122-1128
The Lancet

Series
Screening for prostate cancer

https://doi.org/10.1016/S0140-6736(03)12890-5Get rights and content

Summary

Epidemiologically, screening is justified by the importance of the disease and the lack of prospects for primary prevention, but evidence from natural history is unhelpful since men are more likely to die with, rather than from, prostate cancer. The available screening tests do not always detect men whose lesions could result in future morbidity or mortality. Evidence is limited for the benefits of treatment for localised cancers detected through screening, whereas the evidence for harm is clear. Observational evidence for the effect of population screening programmes is mixed, with no clear association between intensity of screening and reduced prostate cancer mortality. Screening for prostate cancer cannot be justified in low-risk populations, but the balance of benefit and harm will be more favourable after risk stratification. Prostate cancer screening can be justified only in research programmes designed to assess its effectiveness and help identify the groups who may benefit.

Section snippets

Judging the merits of screening

Discussions of screening are conventionally based on the criteria described by Wilson and Jungner.7 The enduring authority of that 1968 account partly reflects the value of its contents, but also the lack of fresh thinking since that time. This area of health policy is unsatisfactory in that support for, or dismissal of, the worth of screening programmes is dominated by advocacy rather than scientific debate. The recurrent confusion in screening policy relates to three aspects of the Wilson and

Epidemiology and natural history

The epidemiology of prostate cancer has been discussed by Henrik Grönberg earlier in this Lancet series.9 Here, we focus on those issues most relevant to screening: the importance of the disorder, the potential for primary prevention, and the extent to which the natural history of prostate cancer renders it amenable to screening.

Effectiveness of screening programmes

In the USA, the reported incidence and mortality of prostate cancer have risen and then fallen49 in ways that have been attributed to PSA screening and treatment changes.50, 51, 52 Similar trends have been seen in Austria.53, 54 In Quebec City, Canada, a 67% reduction in deaths was attributed to screening.55 How strong are these data in suggesting that screening affects mortality? Some of the assertions of effectiveness are naive. For example the findings of the Quebec trial55 are probably the

Conclusions

The balance of proof must be high to justify exposing men older than 50 years to a process where, of 1 million men, about 110 000 with raised PSAs will face anxiety over possible cancer, about 90 000 will undergo biopsy, and 20 000 will be diagnosed with cancer. If 10 000 of these men underwent surgery, about ten would die of the operation, 300 will develop severe urinary incontinence, and even in the best hands 4000 will become impotent. The number of men whose prostate cancer would have

Search strategy and selection criteria

Our review of the published work is built on previous systematic reviews of prostate cancer screening, supplemented by an update of subsequent research from reviews and bibliographies of published articles and publications identified from major bibliographic sources, including Medline, Embase, and Web of Science, focusing on issues relating to MeSH terms “prostatic neoplasms” and “mass screening”, and text terms “prostate cancer” and “screening”.

References (82)

  • HB Carter et al.

    Prospective evaluation of men with stage T1c adenocarcinoma of the prostate

    J Urol

    (1997)
  • AB Jani et al.

    Clinical decision-making in early prostate cancer

    Lancet

    (2003)
  • VE Weldon et al.

    Continence, potency and morbidity after radical perineal prostatectomy

    J Urol

    (1997)
  • T Siegel et al.

    The development of erectile dysfunction in men treated for prostate cancer

    J Urol

    (2001)
  • W Horninger et al.

    Prostate cancer screening in the Tyrol, Austria: experience and results

    Eur J Cancer

    (2000)
  • G Bartsch et al.

    Tyrol Prostate Cancer Screening Group. Prostate cancer mortality after introduction of prostate-specific antigen mass screening in the Federal State of Tyrol, Austria

    Urology

    (2001)
  • SE Oliver et al.

    Comparison of trends in prostate cancer mortality in England and Wales and the USA

    Lancet

    (2000)
  • PC Albertsen et al.

    A comparison of cause of death determination in men previously diagnosed with prostate cancer who died in 1985 or 1995

    J Urol

    (2000)
  • SD Fossa et al.

    No randomised trial of prostate-cancer screening in Norway

    Lancet Oncol

    (2001)
  • G Yamey et al.

    Prostate cancer screening: is it worth the pain?

    San Francisco Chronicle

    (Jan 18, 2002)
  • A Ferriman

    Advocates of PSA testing campaign to silence critics

    BMJ

    (2002)
  • C DiGuiseppi

    US Preventive Services Task Force. Guide to clinical preventive services

    (1996)
  • MM Cookson

    Prostate cancer: screening and early detection

    Cancer Control

    (2001)
  • JMG Wilson et al.

    Principles and practice of screening for disease. Public Health Paper Number 34

    (1968)
  • Criteria for appraising the viability, effectiveness and appropriateness of a screening programme

  • DM Parkin et al.

    Cancer burden in the year 2000: the global picture

    Eur J Cancer

    (2001)
  • A von Eschenbach et al.

    American Cancer Society guidelines for early detection of prostate cancer

    Cancer

    (1997)
  • Office for National Statistics. 1993 Cancer statistics: registrations

    (1999)
  • JL Stanford et al.

    Familial prostate cancer

    Epidemiol Rev

    (2001)
  • CA Coltman et al.

    Prostate Cancer Prevention Trial (PCPT) update

    Eur Urol

    (1999)
  • D Gunnell et al.

    Height, leg length and cancer risk: a systematic review

    Epidemiol Rev

    (2001)
  • M Pollak

    Insulin-like growth factors and prostate cancer

    Epidemiol Rev

    (2001)
  • AW Meikle et al.

    Epidemiology of prostate cancer

    Urol Clin North Am

    (1990)
  • M McGregor et al.

    Screening for prostate cancer: estimating the magnitude of overdetection

    Can Med Assoc J

    (1998)
  • FH Schröder et al.

    Screening for prostate cancer: evidence and perspectives

    BJU Int

    (2001)
  • PC Albertsen et al.

    Competing risk analysis of men aged 55–74 years at diagnosis managed conservatively for clinically localized prostate cancer

    JAMA

    (1998)
  • J Donovan et al.

    Quality improvement report: Improving design and conduct of randomised trials by embedding them in qualitative research: ProtecT (prostate testing for cancer and treatment) study

    BMJ

    (2002)
  • PC Walsh

    Surgery and the reduction of mortality from prostate cancer

    N Engl J Med

    (2002)
  • PC Albertsen et al.

    Long-term survival among men with conservatively treated localized prostate cancer

    JAMA

    (1995)
  • A Reissigl et al.

    PSA-based screening for prostate cancer in asymptomatic younger males: pilot study in blood donors

    Prostate

    (1997)
  • L Maatanen et al.

    European randomised study of prostate cancer screening: first-year results of the Finnish trial

    Br J Cancer

    (1999)
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