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The real impact of mass prostate cancer screening

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New research from the US has produced evidence that annual prostate cancer screening does not translate into a reduction in the amount of deaths from the disease, even among men in their 50s and 60s and those with underlying health conditions.


The research, led by the Washington University School of Medicine in the US, followed more than 76,000 men and showed that although six years of aggressive, annual screening for the cancer led to more diagnoses of tumours, it did not result in fewer deaths.

 

The results of the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial were published online last week in the Journal of the National Cancer Institute.

The study involved men aged between 55 and 74 who were randomly assigned to receive either annual prostate-specific antigen (PSA) tests for six years and digital rectal exams for four years or “routine care”, meaning they had the screening tests only if their physicians recommended them.

The PLCO provides an update on earlier data published in 2009 in the New England Journal of Medicine. The 2009 data had followed the men for seven years and lead author Professor Gerald Andriole, chief urologic surgeon at the Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine, said the data did not show a mortality benefit from screening at that point.

However, as so few men involved in the study had died from any causes, the researchers said it would be premature to make broad generalisations about whether men should continue to be screened. The researchers did recommend against prostate cancer screening for men with a life expectancy of seven to 10 years or less.

Under the updated results, almost all the men were followed for 10 years and over 50 per cent followed for 13 years. Based on these most recent findings, Prof Andriole said that only the youngest men (those with the longest life expectancy) are likely to benefit from screening.

“We need to modify our current practices and stop screening elderly men and those with a limited life expectancy,” he said.  “Instead, we need to take a more targeted approach and selectively screen men who are young and healthy and particularly those at high risk for prostate cancer.” Men who are at a high risk include African-Americans and men with a family history of the disease.

Recently published results of The State of Men’s Health Report, which was carried out in countries across Europe, showed that currently, around three million European men are living with prostate cancer, a number that is expected to increase in line with the ageing population.

Speaking to IMN, Professor Alan White, the world’s first Professor of Men’s Health, based at Leeds Metropolitan University, who worked on the report, said there needs to be a “rethink” about health services directed at men.

“Ordinary men on the street, if they’re going to access all the services that are being provided, and if they have to get up at eight in the morning, and don’t finish work until six in the evening, they don’t get access to most of those services,” he said.

He added that better health promotion should be provided to men from an early age, and the health of working age men should be focused on in order to try and reduce rates of premature death.

“We’ve got to have a fitter healthier population on the way to old age,” he said.

Prof Andriole recommended that men get a baseline PSA test in their early 40s as recent studies have indicated that elevated levels at that age can predict the risk of prostate cancer in later years. Men in their 40s with low PSA levels are very unlikely to develop lethal prostate cancer and could potentially avoid additional testing.

The study detected 12 per cent more prostate tumours among men who were screened annually compared to those who received routine care, at 4,250 tumours versus 3,815. Deaths from prostate cancer did not differ significantly between the groups.

There were 158 deaths from the cancer in the screening group and 145 deaths in the routine-care group. Annual screening tests also did not reduce deaths from prostate cancer among men in their 50s and 60s, as the researchers had hoped.

Furthermore, men diagnosed with prostate cancer who also had a history of heart attacks, strokes, diabetes, cancer or lung and liver disease were far more likely to die from causes other than prostate cancer – a finding that suggests that screening often finds tumours that are not likely to cause harm.

While recommending against mass screening of all men on the basis of age alone, Prof Andriole acknowledged that screening can be useful in select men. He also said that widespread testing has resulted in many men with slow-growing tumours to be over-diagnosed and over-treated with surgery or radiation therapy, the possible side effects of which include incontinence and impotence.

“We have to take a more nuanced approach to determine which men should be screened with PSA in the first place, how frequently they should be tested, the PSA level at which they should be biopsied and whether their cancer warrants aggressive therapy,” he continued.

The PLCO study will continue to follow patients for up to 15 years after they enrolled, and evaluate the effects of prostate cancer screening on mortality.

 

 

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