Screening for prostate cancer in the elderly

Prostate cancer screening is extremely controversial these days. Although nearly 30,000 men die annually of the disease, a large randomized (although many patients in the nonscreening arm were screened) PLCO trial conducted in the USA showed no survival advantage for screening (rate ratio: 1.15; 95% CI: 0.86–1.54) [1]. In addition, despite large screening efforts in the USA, the rate of death from prostate cancer has largely remained unchanged. Epidemiological studies looking at the death rate from prostate cancer across various countries have found that death from prostate cancer often appears to be similar between countries that screen for cancer and those that do not [101]. Furthermore, a recent Cochrane review performed a meta-analysis using the aforementioned prostate-specific antigen (PSA) screening studies, including the PLCO and ERSPC studies. The study found no statistically significant difference in prostate cancer mortality between men randomized to PSA screening and those followed with watchful waiting (rate ratio: 1.0; 95% CI: 0.86–1.17) with ages ranging between 45 and 80 years. The Cochrane review also considered the harm associated with PSA-based screening and diagnostic evaluations from positive tests. The study found that overdiagnosis and overtreatment were common with PSA screenings and treatment, as were morbidities from treatment [2]. Finally, screening and treatment can be associated with significant cost. One study estimated that US$5.2 million must be spent on screening to prevent one prostate cancer death [3]. This debate has led to the US Preventative Task Force giving the recommendation of ‘D’ for prostate cancer screening. This means the US Preventative Task Force panel currently feels that the risks of screening and treatment likely outweigh the benefits, and they have recommended against it [102].

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