Screening for Prostate Cancer with Prostate-Specific Antigen: What's the Evidence?

In October 2011, the U.S. Preventive Services Task Force (USPSTF, or "Task Force") released draft recommendations on prostate cancer screening with prostate-specific antigen (PSA), concluding that "PSA-based screening results in small or no reduction in prostate cancer-specific mortality and is associated with harms related to subsequent evaluation and treatments, some of which may be unnecessary." This statement was accompanied by a grade "D" recommendation, which indicates that in the Task Force's judgment there "is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits." The Task Force, an independent panel of nonfederal (U.S.) experts in prevention and evidence-based medicine, conducts systematic evidence reviews of preventive health care services and makes recommendations about preventive services in primary care. Task Force recommendations do not set U.S. federal policy but can and do influence reimbursement and clinical practice. In this article, we will present evidence the Task Force considered when making its decision, including two highly influential randomized controlled trials (RCTs) of prostate cancer screening, the European Randomized Study of Prostate Cancer (ERSPC) and the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (PLCO). The two trials arrived at different conclusions about the efficacy of routine prostate cancer screening, but similar conclusions about the accompaniment of clinically relevant harms with prostate cancer screening, including overdiagnosis (screen detection of cancers that never would be diagnosed in the absence of screening). We also will present other available evidence on benefits and harms of PSA-based screening and consider that evidence and the findings of ERSPC and PLCO in conjunction with one another.