Mortality Results from a Randomized Prostate-Cancer Screening Trial

Washington University School of Medicine, St. Louis, USA.
New England Journal of Medicine (Impact Factor: 55.87). 04/2009; 360(13):1310-9. DOI: 10.1056/NEJMoa0810696
Source: PubMed


The effect of screening with prostate-specific-antigen (PSA) testing and digital rectal examination on the rate of death from prostate cancer is unknown. This is the first report from the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial on prostate-cancer mortality.
From 1993 through 2001, we randomly assigned 76,693 men at 10 U.S. study centers to receive either annual screening (38,343 subjects) or usual care as the control (38,350 subjects). Men in the screening group were offered annual PSA testing for 6 years and digital rectal examination for 4 years. The subjects and health care providers received the results and decided on the type of follow-up evaluation. Usual care sometimes included screening, as some organizations have recommended. The numbers of all cancers and deaths and causes of death were ascertained.
In the screening group, rates of compliance were 85% for PSA testing and 86% for digital rectal examination. Rates of screening in the control group increased from 40% in the first year to 52% in the sixth year for PSA testing and ranged from 41 to 46% for digital rectal examination. After 7 years of follow-up, the incidence of prostate cancer per 10,000 person-years was 116 (2820 cancers) in the screening group and 95 (2322 cancers) in the control group (rate ratio, 1.22; 95% confidence interval [CI], 1.16 to 1.29). The incidence of death per 10,000 person-years was 2.0 (50 deaths) in the screening group and 1.7 (44 deaths) in the control group (rate ratio, 1.13; 95% CI, 0.75 to 1.70). The data at 10 years were 67% complete and consistent with these overall findings.
After 7 to 10 years of follow-up, the rate of death from prostate cancer was very low and did not differ significantly between the two study groups. ( number, NCT00002540.)

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    • "Prostate cancer mortality and latestage diagnosis have however declined significantly in the last two decades, a decline that started mostly after 1991 (Chu et al., 2003; Smart, 1997). According to some studies, this decline in mortality is due to early detection (PSA screening) although screening for prostate cancer is still controversial (Andriole et al., 2009; Barratt and Stockler, 2009; Schröder et al., 2009; Wolf et al., 2010). In particular for Florida, state-level percentage of late-stage diagnosis decreased 50% since 1981; a decline that accelerated in the 1990s with increased use of prostate specific antigen (PSA) screening. "
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    ABSTRACT: Individual-level data from the Florida Cancer Data System (1981–2007) were analyzed to explore temporal trends of prostate cancer late-stage diagnosis, and how they vary based on race, income and age. Annual census-tract rates were computed for two races (white and black) and two age categories (40–65, >65) before being aggregated according to census tract median household incomes. Joinpoint regression and a new disparity statistic were applied to model temporal trends and detect potential racial and socio-economic differences. Multi-dimensional scaling was used as an innovative way to visualize similarities among temporal trends in a 2-D space. Analysis of time-series indicated that late-stage diagnosis was generally more prevalent among blacks, for age category 40–64 compared to older patients covered by Medicare, and among classes of lower socio-economic status. Joinpoint regression also showed that the rate of decline in late-stage diagnosis was similar among older patients. For younger patients, the decline occurred at a faster pace for blacks with rates becoming similar to whites in the late 1990s, in particular for higher incomes. Both races displayed distinct spatial patterns with higher rates of late-stage diagnosis in the Florida Panhandle for whites whereas high rates clustered in South-eastern Florida for blacks.
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    • "two large prospective trials one of which showed a 21% reduction in prostate cancer mortality while the other found no effect (Andriole et al, 2009; Schröder et al, 2012). Although these trials came to different conclusions about the efficacy of PSA screening, there is general agreement that better strategies for avoiding overtreatment of early cancers are needed (Cuzick et al, 2014) before screening can be widely adopted. "
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    • "However, the recent decline in PC related mortality rates is now being discussed to be partially explained by the improved treatment and earlier diagnosis due to a broad standard PSA screening in economically developed countries [4, 5]. As the standard PSA screening in the early diagnosis of human PC remains a very controversial issue, novel, reliable molecular PC markers are needed [6–8]. "
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