Monthly Archives: August 2014

PROSTATE CANCER SCREENING, LIKE BREAST CANCER SCREENING, NO BENEFIT ON ALL-CAUSE MORTALITY ie HEALTHY SURVIVAL.

17 August 2014: neil.burman@gmail.com

Sadly, this month’s publication of the biggest-ever trial of Prostate Screening , in 162 000 men across Europe followed  for a mean of 11years, showed no benefit in all-cause mortality, same as was found in  the 5 previous major RCTrials,  or  trials  of xray mammography:.

Lancet. 2014 Aug 6. Schröder FH1 ea  Screening and prostate cancer mortality: results of the western European Randomised Study of Screening for Prostate Cancer (ERSPC) at 13 years of follow-up ie 1.78  million patient years, in some 162 000 men  aged 55 to 69, randomized  to either a screening arm or a control group. If PSA was 3ng/ml or more, they were offered a biopsy. Screening took place on average every four years. Mean follow-up was 11 years.  7408 prostate cancer cases were diagnosed in the intervention group and 6107 cases in the control group. The rate ratio of prostate cancer incidence between the intervention and control groups was  1·66 (1·60-1·73) after 11 years, and 1·57 (1·51-1·62) after 13 years. The rate ratio of prostate cancer mortality was 0·85 (0·70-1·03) after 9 years, 0·78 (0·66-0·91) after 11 years, and 0·79 (0·69-0·91) at 13 years. The absolute risk reduction of death from prostate cancer at 13 years was 0·11 per 1000 person-years or 1·28 per 1000 men randomised, which is equivalent to one prostate cancer death averted per 781 (95% CI 490-1929) men invited for screening or one per 27 (17-66) additional prostate cancer detected. After adjustment for non-participation, the rate ratio of prostate cancer mortality in men screened was 0·73 (95% CI 0·61-0·88). Despite our findings, further quantification of harms and their reduction are still considered a prerequisite for the introduction of populated-based screening.
                                                                                                                   As a 2012 independent analysis on the web says,   Updated data from ERSPC trial still show no impact on all-cause mortality:    A new article in the New England Journal of Medicine this week has updated the prostate cancer-specific and all-cause (overall) mortality data from the European Randomized Study of Screening for Prostate Cancer (ERSPC).       This latest analysis of data by Schröder et al., and based on a randomized comparison of screening (with regularly scheduled PSA tests) as opposed to non-screening, has shown the following results in the predefined, core group of men aged between 55 and 69 years at the time of enrollment:
  • The average (median) follow-up for men in the core group was 11 years.
  • There was no significant difference in all-cause mortality between the groups who were or were not screened for risk of prostate cancer.
  • Reductions in the risk for prostate cancer-specific mortality in men randomized to the screening group as compared to the unscreened group were
    • An absolute reduction of 0.10 prostate cancer deaths per 1,000 person-years
    • An absolute reduction of 1.07 prostate cancer deaths per 1,000 men who underwent screening
    • A relative overall reduction in the risk of prostate cancer deaths in the screening group of 21 percent
    • A relative overall reduction in the risk of prostate cancer deaths in the screening group of 29 percent after adjustment for non-compliance with screening
  • To prevent a single case of prostate cancer-specific mortality
    • 1,055 men would need to be invited to be screened
    • 37 cases of prostate cancer would need to be detected

The authors conclude that this analysis, which adds two additional years of follow-up data to the data originally published in early 2009, shows that “PSA-based screening significantly reduced mortality from prostate cancer but did not affect all-cause mortality.”

‘These new data are unlikely to help to clarify the debate over the value of mass screening for prostate cancer. From one point of view one can use them to argue that screening can prevent between 20 and 30 percent of prostate cancer-specific deaths. From the alternative point of view, one can argue that screening a million men would indeed prevent about 950 prostate cancer-specific deaths, but would also lead to the potential over-treatment of 36 out of every 37 cases of prostate cancer identified, and would have no impact whatsoever on overall mortality’.

Yoon Jae Lee, O.ea.The study was conducted using existing systematic reviews.   Results  In a total of 400 000 men  in 6 included trials from Europe, USA, and Canada, followed for about 10 years,  ie 4million patient-years, Prostate-cancer-specific mortality was not reduced based on similar prior reviews (relative risk [RR] 0.93; P=0.31). The detection rate of stage 1 prostate cancer was not greater, with a RR of 1.67 (95% CI, 0.95-2.94). No difference in all-cause mortality was observed between the screening and control groups (RR, 0.99; 95% CI, 0.98-1.01, P=0.50).
Hayes JH1, Barry MJ2  Harvard Medical School, Boston, Massachusetts  review  evidence from randomized trials and related modeling studies examining the effect of PSA screening vs no screening on prostate cancer-specific mortality and to suggest an approach balancing potential benefits and harms during a longer follow-up (level B evidence).     Available evidence favors clinician discussion of the pros and cons of PSA screening with average-risk men aged 55 to 69 years. Only men who express a definite preference for screening should have PSA testing. Other strategies to mitigate the potential harms of screening include considering biennial screening, a higher PSA threshold for biopsy, and conservative therapy for men receiving a new diagnosis of prostate cancer.