Dutch expert: PSA screening is here to stay despite debate

Fri, 11 Apr 2014

Despite the continuing debate regarding the harms and benefits of PSA screening, prostate cancer experts from the Netherlands are convinced that PSA screening “is here to stay.”

We are now at a stage where we acknowledge the existence of pros and cons of screening which prompts a need to find a way how to deal with the balance between the two. Despite screening being deemed unethical by some, PSA based screening is here to stay,” said Dr. Monique Roobol of the Erasmus MC, Dept. of Urology in Rotterdam (NL).

Roobol, a moderator and presenter at the Joint Session of the European Association of Urology (EAU) and the Japanese Urological Association (JUA), said the results of the randomized screening trials conducted in Europe and the US have fuelled the discussion on the balance between the pros and cons for prostate specific antigen (PSA)-based prostate cancer screening.

Roobol explained that the current debate is basically underpinned by two opposing camps or arguments. “One extreme is represented by those who were against screening for PCa and considered it unethical; the opposite view are represented by investigators who argued that men should not be denied the opportunity of early detection and treatment,” she said.

Way back in the early 1990s, experts were already warning of over-diagnosis and overtreatment, and it was in 1993 that both the European Randomized study of Screening for Prostate Cancer (ERSPC) as well as the prostate arm of the Prostate Lung Colorectal and Ovary screening trial (PLCO) were initiated.

In 2009, both randomized trials reported the results on the main endpoint PCa specific mortality. While it was anticipated that both trials would provide a definite answer to the question of harm versus benefits, the opposite was true.

“While the European trial (ERSPC) showed a significant PCa mortality reduction in favor of screening the US trial (PLCO) did not,” Roobol added.

Mentioning various state-of-the-art analysis to quantify and compare pros and cons in PSA-based prostate cancer screening, Roobol noted that for individual patients, however, these estimates are of less importance. “The only thing that really matters (for patients) is: am I at risk of having a life threatening PCa? If so, how likely is he willing to undergo (repeat) testing, and if diagnosed, treatment with potential long-term side effects?” added Roobol.

Risk stratification

Saying that PSA testing is here to stay and cannot be stopped despite strong recommendations against it, Roobol highlighted the query often asked by doctors: “What should clinicians do when a man comes with a request for a PSA test? The key words are risk stratification, informed consent and shared decision making,” she said.

She emphasised that the goal of risk stratification is to find out whether a patient, as compared to other men, faces an elevated risk of having a life threatening PCa, and if so, whether he should be advised to be tested or not.

According to Roobol, that goal implies two crucial factors. First, that a “one-size fits all” approach should be abandoned in favor of individualized, risk-stratified screening, and

second, that risk stratification could be improved, by considering factors other than PSA alone.

In her concluding remarks, Roobol underscored that population-based estimates are difficult to translate to an individual level.

“In daily clinical practice, reliable information enabling weighing the individually assessed risk of missing a diagnosis of a life threatening PCa versus the risk of unnecessary testing and over-diagnosis/overtreatment is indispensable. This will require ongoing commitment from researchers, physicians and men in developing the optimal tools and the willingness to fully

appreciate and discuss the PSA screening pros and cons when needed,” said Roobol.

Source: Urology Beyond Europe; Prostate cancer: PSA screening Joint Session of the European Association of Urology (EAU) and the Japanese Urological Association (JUA); 29th Annual EAU Congress, Stockholm, Sweden.