Platinum Priority – Prostate CancerEditorials by Neil E. Martin on pp. 361–362 of this issue and by Monique J. Roobol on pp. 363–364 of this issueOpportunistic Testing Versus Organized Prostate-specific Antigen Screening: Outcome After 18 Years in the Göteborg Randomized Population-based Prostate Cancer Screening Trial
Introduction
It has been shown that screening for prostate cancer (PC) with prostate-specific antigen (PSA) testing reduces PC-specific mortality but carries a high risk of overdiagnosis [1], [2]. In the European Randomized Study of Screening for Prostate Cancer (ERSPC) at 13 yr of follow-up, 781 men needed to be invited to screening and 27 men needed to be diagnosed to prevent one PC death [2]. However, no country has yet introduced a national PSA-based screening program, so PSA measurements performed on asymptomatic men with no prior PC diagnosis, aside from those enrolled in organized screening trials, are taken as part of opportunistic PSA testing.
Several studies on breast and cervical cancer screening have indicated that opportunistic screening is less effective and less cost-effective than an organized approach [3], [4], [5] and the Council of the European Union has recommended that screening for breast, cervical, and colorectal cancer should be conducted in organized programs [6]. It is currently unknown whether opportunistic PSA testing is as effective as organized PSA screening in reducing PC mortality, and whether there is a relationship between organized screening versus opportunistic testing and the risk of overdiagnosis. Despite the lack of evidence in support of opportunistic screening, there is high uptake of this form of PSA testing in many Western countries [7], [8], [9], [10]. According to a recent estimate, >50% of all Swedish men aged 55–69 yr have had a PSA test [10], which has resulted in rapidly increasing PC incidence during the last decades [11], [12].
The aim of this study was to investigate the effectiveness of organized and opportunistic screening in reducing PC mortality, measured as the number needed to invite (NNI), and the amount of overdiagnosis, estimated as the number needed to diagnose (NND), in the Swedish center of the ERSPC.
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Patients and methods
After approval by the ethics committee at the University of Gothenburg in 1994, the Göteborg randomized population based prostate cancer screening trial was established in 1995 (registered as Current Controlled Trials ISRCTN54449243). Since 1996, the study has contributed to the Swedish arm of ERSPC. The Göteborg study has previously been described in depth [1]. In summary, 20 000 of the men recorded in the population register as living in Gothenburg (born 1930–1944) were computer-randomized,
Results
Following randomization, a total of 101 men were excluded (Fig. 1). During 18 yr of follow-up, 1396 men were diagnosed with PC in the screening group, of whom 1022 were diagnosed as a result of organized screening, compared to 962 cancer cases detected among controls, of whom 361 were asymptomatic men diagnosed by opportunistic screening. In the screening group, 87% complied with the biopsy recommendation. The median age and PSA at diagnosis were 65.8 yr (interquartile range [IQR] 62.2–68.3 yr)
Discussion
To the best of our knowledge, this is the first study comparing organized and opportunistic PSA screening using NNI and NND. The results indicate that similar to breast and cervical cancer screening, organized screening is more effective than opportunistic screening in reducing disease-specific mortality. After 18 yr, PC incidence in the control group had increased by almost 70% compared to the pre-screening era, indicating considerable uptake of opportunistic screening in the control group.
Conclusions
Our results indicate that organized intense screening effectively reduces PC mortality but is associated with considerable overdiagnosis; after 18 yr of follow-up, 13 men must be diagnosed to prevent one PC death compared to a situation with no PSA testing. Opportunistic PSA testing had little if any effect on PC mortality, and was associated with greater overdiagnosis in comparison to organized screening, as estimated by NND. If, after careful counseling, a man chooses to participate in PSA
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