A previous study reported no statistically significant difference in prostate cancer-specific mortality in men aged 70 years or older who initiated PSA-based screening, compared with those who were not offered screening.2 In contrast, they did observe a reduction among men aged 55-69 years. The absence of a mortality reduction in men aged 70 years or older is likely explained by the limited life expectancy of this age group. Since comorbidity also affects life expectancy,3,4 we assessed whether there was a difference in the effect of PSA-based screening on prostate cancer-specific mortality in men with and without comorbidities. We hypothesised that young men (55-69 years) with comorbidities might not benefit from screening, whereas older men (≥70 years) without comorbidities might.
Our study demonstrated that PSA-based screening did not reduce metastatic disease or prostate cancer-specific mortality among men aged 55–69 years with at least one comorbidity, likely due to competing mortality risks. In contrast, men in the same age group without any comorbidities showed a reduction in both relative and absolute risks of metastatic disease and prostate cancer-specific mortality. The number needed to invite (NNI) of 185 and number needed to diagnose (NND) of 10 to prevent one prostate cancer death were more favourable than previously reported for the overall cohort in this age group (NNI 243 and NND 14).2 This suggests that screening efficiency improves when the target group is refined, and only individuals with sufficient life expectancy are included.
Our study also demonstrated that men who started screening from the age of 70 showed no reduction in prostate cancer-specific mortality, regardless of comorbidity status. Previous studies that demonstrated that the protective effect of screening diminishes 7 to 9 years after cessation suggested that an upper age limit might not be appropriate for all men, particularly those in good health.1,2,5 However, even in the absence of comorbidity, PSA-based screening did not reduce the risk of prostate cancer-specific mortality and therefore should be discouraged in this age group. This emphasises that chronological age remains the dominant factor due to competing mortality risks.
In conclusion, this study underscores the importance of targeting prostate cancer screening only to men with sufficient life expectancy to benefit, assessed both by age and comorbidity. These findings argue for incorporating comorbidity-adjusted life expectancy assessments into routine screening decision-making, potentially even before PSA testing is initiated.
Written by: Sanne F. Westerhout, MD,1 P.J. van Leeuwen, MD, PhD,2 and M.J. Roobol, PhD1
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Antoni van Leeuwenhoek – Netherlands Cancer Institute, Amsterdam, The Netherlands
- Roobol MJ, de V, II, Månsson M, Godtman RA, Talala KM, den Hond E, et al. European Study of Prostate Cancer Screening - 23-Year Follow-up. N Engl J Med. 2025;393(17):1669-80.
- de V, II, Meertens A, Hogenhout R, Remmers S, Roobol MJ. A Detailed Evaluation of the Effect of Prostate-specific Antigen-based Screening on Morbidity and Mortality of Prostate Cancer: 21-year Follow-up Results of the Rotterdam Section of the European Randomised Study of Screening for Prostate Cancer. Eur Urol. 2023;84(4):426-34.
- de Groot V, Beckerman H, Lankhorst GJ, Bouter LM. How to measure comorbidity. a critical review of available methods. J Clin Epidemiol. 2003;56(3):221-9.
- Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373-83.
- Berglund A, Garmo H, Tishelman C, Holmberg L, Stattin P, Lambe M. Comorbidity, treatment and mortality: a population based cohort study of prostate cancer in PCBaSe Sweden. J Urol. 2011;185(3):833-9.