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Opportunistic Testing Versus Organized Prostate-specific Antigen Screening: Outcome After 18 Years in the Göteborg Randomized Population-based Prostate Cancer Screening Trial

European Urology [Epub ahead of print]

Abstract

Background

It has been shown that organized screening decreases prostate cancer (PC) mortality, but the effect of opportunistic screening is largely unknown.

Objective

To compare the ability to reduce PC mortality and the risk of overdiagnosis between organized and opportunistic screening.

Design, setting, and participants

The Göteborg screening study invited 10 000 randomly selected men for prostate-specific antigen (PSA) testing every 2 yr since 1995, with a prostate biopsy recommended for men with PSA ≥2.5 ng/ml. The control group of 10 000 men not invited has been exposed to a previously reported increased rate of opportunistic PSA testing. Both groups were followed until December 31, 2012.

Outcome measurements and statistical analysis

Observed cumulative PC incidence and mortality rates in both groups were calculated using the actuarial method. Using historical data from 1990–1994 (pre-PSA era), we calculated expected PC incidence and mortality rates in the absence of any PSA testing. The number needed to invite (NNI) and the number needed to diagnose (NND) were calculated by comparing the expected versus observed incidence and mortality rates.

Results and limitations

At 18 yr, 1396 men were diagnosed with PC and 79 men died of PC in the screening group, compared to 962 and 122, respectively, in the control group. In the screening group, the observed cumulative PC incidence/mortality was 16%/0.98% compared to expected values of 6.8%/1.7%. The corresponding values for the control group were 11%/1.5% and 6.9%/1.7%. Organized screening was associated with an absolute PC-specific mortality reduction of 0.72% (95% confidence interval [CI] 0.50–0.94%) and relative risk reduction of 42% (95% CI 28–54%). There was an absolute reduction in PC deaths of 0.20% (95% CI –0.06% to 0.47%) and a relative risk reduction of 12% (95% CI –5 to 26%) associated with opportunistic PSA testing. NNI and NND were 139 (95% CI 107–200) and 13 for organized biennial screening and 493 (95% CI 213– −1563) and 23 for opportunistic screening. The extent of opportunistic screening could not be measured; incidence trends were used as a proxy.

Conclusions

Organized screening reduces PC mortality but is associated with overdiagnosis. Opportunistic PSA testing had little if any effect on PC mortality and resulted in more overdiagnosis, with almost twice the number of men needed to be diagnosed to save one man from dying from PC compared to men offered an organized biennial screening program.

Patient summary

Prostate-specific antigen (PSA) screening within the framework of an organized program seems more effective than unorganized screening.

Take Home Message

Opportunistic prostate-specific antigen (PSA) screening is less effective than organized screening and associated with more overdiagnosis. If, after careful counseling, a man chooses to participate in PSA screening, it should be in an organized program at sufficient intervals and with adequate follow-up.

Keywords: Opportunistic, Organized, Overdiagnosis, Prostate cancer, Prostate-specific antigen, Screening.

Footnotes

a Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden

b Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden

c Departments of Laboratory Medicine, Surgery (Urology), and Medicine (GU Oncology), Memorial Sloan-Kettering Cancer Center, New York, NY, USA

d Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK

e Department of Laboratory Medicine, Lund University, Skåne University Hospital, Malmö, Sweden

f Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden

lowast Corresponding author. Department of Urology, Institute of Clinical Sciences, Bruna Stråket 11 B, SE-413 45 Gothenburg, Sweden. Tel. +46 313423809; Fax: +46 31415617.