Critical role of prostate biopsy mortality in the number of years of life gained and lost within a prostate cancer screening programme

Therapy (data synthesis) Level of Evidence 2b.

What's known on the subject? and What does the study add? The efficacy of prostate cancer screening using PSA testing is still being debated, with conflicting results in randomized trials. The study shows that, even using the hypothesis most favourable to prostate cancer screening with PSA, the net number of years of life does not favour screening.

To evaluate the impact of the implementation a prostate-specific antigen (PSA) screening programme using the European Randomized Study of Screening for Prostate Cancer (ERSPC) results and taking into account the impact of prostate biopsy and over-treatment on mortality.

We used a model based on the number of years of life gained and lost owing to screening, using data reported in the ERSPC. • We conducted a critical evaluation of the ERSPC results and of the Swedish arm of the study.

Accounting for biopsy-specific mortality and for over-treatment, the balance of number of years of life was negative in the ERSPC study, with an estimated loss of 3.6 years of life per avoided death. • The number of years of life becomes positive (real gain) only when fewer than 666 screened individuals are required to avoid one death. • We found that in the Swedish arm of the ERSPC there was a biopsy rate of 40% compared with 27% in the ERSPC overall. The over-treatment rate was also greater with 4.1% compared with 3.4% overall. • For the last 20 years, there has been a marked difference in prostate cancer-specific mortality between Sweden and the rest of Europe: in 2005, for the age group 65-74 the rate was 140 per 100,000 person years in Sweden and ~80 per 100,000 for the rest of Europe.

Overall, PSA testing in Europe is associated with a loss in years of life and should thus not be recommended.