EAU 2017: At what age should a PSA-based screening program start? 20-year results from the Göteborg randomized population-based prostate cancer screening study

London, England (UroToday.com) PSA screening is recommended by most major urologic associations internationally, but there is no guidelines or evidence regarding when to start PSA screening. EAU guidelines recommend after age 50, or after age 45 if high-risk. NCCN guidelines say to start at age 40. The AUA says to screen men over 55, but to consider higher-risk men under 55.

The Göteborg randomized population-based prostate cancer screening study is one of the most oft cited papers on prostate cancer screening. In the Göteborg screening study, which started in 1995 and randomized 10,000 men aged 50 to 65 years to biennial PSA testing and 10,000 men to a control group, the upper age limit for invitation was 67-71 (average 69) years. Follow-up was complete up to December 2014 (20 years). Of note, the Göteborg screening study was the only cohort within the larger EORTC study that started screening at age 50 rather than 55.

In this particular abstract, the authors attempt to understand the age at which prostate cancer screening should be initiated. They modelled a scenario where all men in the study were presumably followed from age 50. To evaluate whether the effect of screening on PC-mortality is related to age at starting screening, they studied the dependence of age at randomization to PC mortality reduction in a logistic regression model truncated at age 70, 75 and 80 years respectively. They compared the patients against historical controls as well.

The effect of PSA screening on PC-mortality was inversely associated with the age at start – younger men had the greatest benefit. Below, in figures 1-3, the odds ratio of cancer-specific death (screened vs. control) are plotted against age at randomization. In Figure 1, men screened between age 50 and 65 demonstrated less likely PCa specific death by age 70. In Figure 2, men screened between age 55 and 62.5 demonstrated less likely PCa specific death by age 75. In Figure 3, none of the men screened between age 60 and 65 demonstrated any benefit over control, as it related to risk of cancer death by age 80.

chart 3

Based on this, the authors conclude that screening should start no later than at age 55. The limited mortality reduction in men starting screening at 60 and higher might be attributed to a shorter time-span of screening as screening was stopped at age 70.

While an interesting study, it doesn’t change management, as most guidelines already adhere to this. In fact, many are more inclusive of younger men.

This study does not address when to stop screening, as it doesn’t capture a large proportion of patients screened past age 65.

Presented by: Sigrid Carlsson

Co-authors: Arnsrud Godtman R., Holmberg E., Lilja H., Månsson M., Stranne J., Hugosson J.

1. Memorial Sloan Kettering Cancer Center, Dept. of Urology, New York, United States of America
2. Sahlgrenska Academy, Dept. of Urology, Gothenburg, Sweden
3. Sahlgrenska Academy, Dept. of Oncology, Gothenburg, Sweden
4. Memorial Sloan Kettering Cancer Center, Dept. of Surgery, Malmö, Sweden

Written by: Thenappan Chandrasekar , Clinical Fellow, University of Toronto
Twitter: @tchandra_uromd

at the #EAU17 -March 24-28, 2017- London, England