Abstract
Objective To determine the potential effect of implementing population-based prostate-specific antigen (PSA) screening in England on overdiagnosis and testing rates compared with the current opportunistic testing policy.
Design Statistical modeling study. English data on rates of prostate cancer by stage, symptomatic and asymptomatic PSA testing, and life expectancy were merged with epidemiological assumptions on lead time to evaluate plausible overdiagnosis and PSA testing rates from an organized population-based program, in comparison with the current opportunistic policy. In the base-case scenario, organized screening increased the rate of asymptomatic PSA testing (screening) in men aged 50 – 69 year and decreased PSA testing in older men. An alternative modeling approach estimated change in overdiagnosis using data from the CAP trial, and current asymptomatic cancer detection rates.
Setting England, 2018/19.
Participants Adult men.
Main outcome measures Rates of PSA testing, early-stage prostate cancer incidence, and overdiagnosis (prostate cancer that would not be diagnosed in a man’s lifetime but for the PSA test).
Results In the base scenario, introduction of population-based screening led to an approximate 25% reduction in both PSA testing and overdiagnosis rates in the target population compared with the current policy. This was due to the anticipated decrease in PSA testing and overdiagnosis in men aged 70+ years being larger than the projected increase in PSA testing and overdiagnosis in men 50-69 years. The overall incidence of early-stage cancer prostate cancer was similar. Population-based screening was found to detect more early-stage cancers that were not overdiagnosed, and therefore likely to have a greater impact on prostate-cancer morbidity and mortality than current policy. Findings were robust in sensitivity analyses including an entirely separate modeling approach.
Conclusion Opportunistic screening policies in England have led to high rates of overdiagnosis and PSA testing. In comparison with current policy, a risk-adapted, population-based prostate cancer screening program would likely reduce the number of PSA tests and overdiagnoses, and increase benefits of PSA testing from reduced prostate-cancer mortality Population health in England could be improved by either adopting an organized program or by prohibiting PSA testing of asymptomatic men in primary care.
Competing Interest Statement
Dr. Vickers is named on the patent for the statistical model that has been licensed and commercialized as the 4Kscore by OPKO Diagnostics. Drs. Vickers receives royalties from sales of this test and owns stock options in OPKO.
Funding Statement
This work was supported in part by the National Institutes of Health/National Cancer Institute (NIH/NCI) with a Cancer Center Support Grant to Memorial Sloan Kettering Cancer Center [P30 CA008748], a SPORE grant in Prostate Cancer to Dr. H. Scher [P50-CA92629].
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Footnotes
Funding: This work was supported in part by the National Institutes of Health/National Cancer Institute (NIH/NCI) with a Cancer Center Support Grant to Memorial Sloan Kettering Cancer Center [P30 CA008748], a SPORE grant in Prostate Cancer to Dr. H. Scher [P50-CA92629].
Conflicts of interest: Dr. Vickers is named on the patent for the statistical model that has been licensed and commercialized as the 4Kscore by OPKO Diagnostics. Drs. Vickers receives royalties from sales of this test and owns stock options in OPKO. The test is not available in the UK or Europe.
Some minor typographical errors fixed. Once sentence added to discussion showing how a prior paper supports some of the findings reported here.
Data Availability
All data produced in the present work are contained in the supplementary material
