Screening of prostate cancer. Is it needed? Russian experience

The incidence rate of prostate cancer (PC) in Russia has increased from 9.3 to 16.5 per 100000 person-years making it the 4th commonest form of cancer in men. In spite of lack of evidence to justify the wide spread incorporation of PSA screening it continues to gain popularity. We present the results of the screening study, which was initiated at Blokhin Cancer Center in 1996.

1129 healthy volunteers, 40-80 years old were recruited into the screening arm. Participants underwent 3 screening tests including total PSA measurement, digital rectal examination (DRE) and transrectal ultrasound (TRUS). 6-10 core biopsies were performed in patients with suspicious findings on DRE or TRUS and patients with PSA greater than 4 ng/ml. The control arm included 943 patients who were referred to our center between 1996 and 2001.

Five yearly rounds of screening were performed with an overall cancer detection rate of 5.7% (64). 54 cancers were detected in the first round, 6 in the second, 3 in the third, 1 in the fourth and none in the fifth round. In patients with PSA between 4 and 10 ng/ml the sensitivity of total PSA was 92% with specificity 63%. The majority of patients with high grade PC (21 of 22) had PSA above 4 ng/ml. The sensitivity of DRE reached 54%, with a specificity 94% and PPV 24.7%. The sensitivity of TRUS was 65% with a specificity 92%, and PPV 22.4%. In the control arm prostate cancer was diagnosed in 489 (52%) of 943 patients with 79% having either locally advanced or metastatic disease. On the contrary, 80% of men in screening arm had clinically localized disease. 41% (22) of screened patients had high grade disease compared to 57% (538) in the control arm. Over 50% of screen detected patients were treated with radical prostatectomy or radiotherapy compared to only 25% in clinically diagnosed group. The overall 8-year survival of patients in the screening arm treated with definite therapy (radiotherapy or radical prostatectomy) was better than in patients treated conservatively, 66% versus 43% (p = 0.047). However, when adjusted to the stage the difference in survival was lost, 74% versus 56% (p = 0.2).

Screening of PC enables detection of the disease at an earlier, localized stage. The increased detection of cases with organ-confined PC is hoped to result in a decreased number of cancer-specific deaths.