European views on PSA screening debate
The controversial debate regarding the benefits and harms of PSA screening for prostate cancer took centre stage in the concluding plenary session of the 28th Annual EAU Congress held in Milan last Tuesday.
In the last update session, European views regarding the prostate-specific antigen (PSA) screening were presented by Dr. Jonas Eigar Hugosson of the Institute of Clinical Sciences, Sahlgrenska Academy, Göteborg University in Sweden, Mr. Tom Hudson (Dublin, IE) chair of the patient’s group Europa Uomo, and EAU Secretary General Prof. Per-Anders Abrahamsson (Malmö, SE).“The effect of PSA testing is largely dependent upon how you screen and which population you screen. Present studies speak against a too limited screening effort,” said Hugosson who gave an update overview of the European Randomized Study of Screening for Prostate Cancer (ERSPC) study.
The ERSPC study, one of the two biggest randomised studies on prostate cancer screening, differed from the U.S. Prostate, Lung, Colon, and Ovarian (PLCO), which highlighted the harms of treatment and the seemingly negligible benefit of screening. PSA testing has prompted a heated debate in the US particularly after the United States Preventive Services Task Force (USPSTF) recommended against PSA screening in healthy men. Their advice, issued in October 2011, focused on potential risks which can outweigh possible survival benefits.
The ERSPC, meanwhile, showed that analysis of recent data with a median 11-year follow-up indicated a 21% reduction in prostate cancer mortality, particularly in younger men. On the other hand, the main critique against the PLCO study was the contamination of the control arm, since there were high rates of PSA testing among men who were included in the control arm.
In his presentation, Hugosson noted that “at the moment a men should be informed of the pros and cons with PSA testing.”
“And if he chose to be tested this should be done in an organised fashion,” added Hugosson, reiterating the position of ERSPC lead investigator Prof. Fritz Schroder, who earlier spoke in the congress about PSA screening, that “ shared decision-making is necessary and that well-informed men cannot be denied PSA-driven testing.”
Providing the patient’s perspective Hudson lamented the fact that patients are having difficulty with the medical jargon of their doctors. “My appeal to all physicians is let us understand each other. Please don’t use language that we don’t understand since what we need is a simple and clear explanation, which is of crucial importance,” Hudson said.
He also lamented the fact that doctors and specialists themselves are endlessly debating the issue of prostate screening. “We appreciate your fantastic efforts to find cure and treatment, but cut the confusion, if I may put it bluntly,” Hudson said referring to the continuing debate on PSA screening in the US.
Saying that with the disagreement among prostate cancer experts, Hudson said the debate has only led to more confusion among patients. “Many patients are uncertain of taking decisions, and this has not contributed either to a healthy awareness among the general public of the impact or seriousness of prostate cancer,” he said.
Meanwhile, Abrahamsson tackled the main issues for and against PSA screening and said three key questions need to be answered, namely: what are the benefits of treatment of early detected prostate cancer, what are the harms, and does PSA-based screening decrease prostate cancer-specific or all-cause mortality. He also stressed the importance of having diagnostic tools such as blood, urine and genetic biomarkers and the role of imaging techniques, which have become more sophisticated in recent years.
Returning to the key question whether patients should accept PSA-based screening, Abrahamsson quoted Ian Markham who wrote in 1998 in the British Medical Bulletin that “at the heart of the screening debate lies the ethics of information.”
“In the absence population screening, the EAU advises men who consider screening by PSA testing and prostate biopsy to obtain information on the risks and benefits of screening and individual risk assessment,” said Abrahasson in his closing remarks.