Recently, results from 2 large prostate cancer screening trails were reported in the New England Journal of Medicine and the topic of prostate cancer detection has received significant attention in the national media. Although, both studies are inconclusive close examination of them yield important information about prostate cancer screening. The PLCO (Prostate, Lung, Colon, Ovarian) Cancer Screening trial included 77,000 men in the United States randomly assigned to a screening or control group. It has been reported that this trial failed to demonstrate a benefit from prostate cancer screening with annual PSA testing and digital rectal examination. It may not however, be accurate to conclude from this study that prostate cancer screening is not beneficial since there are several limitations to this study that compromise the published conclusions. In other words there are several explanations to explain why this study failed to detect a survival benefit for men undergoing prostate cancer screening even if one existed. Plausible explanations include: 1) The follow up in this study may not have been long enough to detect a benefit for screening since death from prostate cancer typically occurs more that 10 years after the diagnosis of prostate cancer. 2) The PSA cut off (4.0 ng/ml) used to recommend prostate biopsy in the PLCO study is likely too high and may have resulted in delayed detection of cancers after they were no longer curable. 3) More than 40% of men in the study had already been evaluated with a PSA test, and 50% of the patients in the “control” arm of the study underwent prostate cancer screening by their personal physician during the study period. Therefore, a positive effect for screening may have been obscured by this study contamination.

In contrast to the PLCO study, the ESPRC (European Randomized Study of Screening for Prostate Cancer) which screening 182,000 men in 7 European countries every 4 years demonstrated a benefit for prostate cancer screening. In this study prostate cancer screening reduced the risk of prostate cancer death by 20 percent, but 48 additional men needed to be treated for prostate cancer to prevent each prostate cancer death. This study supports the use of PSA-based prostate cancer screening for appropriately selected men, but also highlights the potential risks of over diagnosis and treatment of prostate cancer.

Although there are many unanswered regarding prostate cancer the propensity of evidence supports prostate cancer screening in appropriately selected men. The American Urological Association (AUA) continues to recommend routine prostate cancer screening for those men wishing to be screened.  The AUA has revised it’s recommendation to begin screening with a baseline PSA test and digital rectal examination at the age of 40. They also recommend against the use of a specific PSA cut off, but rather to base the recommendation for prostate biopsy on other factors such as age, family history, ethnicity and the digital rectal examination in addition to the PSA value. The rate of PSA rise (PSA velocity) is also an important factor to consider in determining the need for prostate biopsy.

AUA Prostate Screening Guidelines