Physician's Journal Morning Post: IS PSA typical of overdiagnosis and overtreatment?

Recently, researchers from the Fred Hutchinson Cancer Research Center in the United States used the latest data to re evaluate the profound impact of prostate specific antigen (PSA) screening strategy.the study suggests that for older men, it is possible to improve prostate cancer screening by stopping or reducing the frequency of detection, and adopting more conservative biopsy standards. Although the research model has not been confirmed, these strategies have the potential to improve prostate cancer screening; for men with low PSA level, it is possible to extend the screening Interval time to improve the pros and cons of prostate cancer screening.(nengl J Med. Online, June 18) PSA was widely used in the early 1990s, which led to a rapid increase in the number of prostate cancer diagnosed, and the mortality rate decreased by half in the next 25 years.in recent 10 years, with the preliminary results of the related "pros and cons" and the opposition voice of professional societies, the main reasons why people no longer actively accept screening have been found. Althoughdoes not reflect the trend of the number of metastatic prostate cancer patients, there is some evidence that the incidence rate of metastatic prostate cancer before 2010 may be rising.there are many reasons for the decrease in PSA screening, but part of the reason seems to be the wrong interpretation of the existing randomized trial data and the lack of attention to the follow-up time in assessing the pros and cons. The authors use the latest data to re evaluate the possible long-term effects of PSA screening.at present, the mainstream view on PSA screening is that "two large-scale, randomized, controlled trials on PSA screening show that the benefits of screening are not clear or not", and the author thinks that this view is problematic.PSA screening is open to question. PLCO test showed that the incidence rate of cancer increased in the screening group. However, after 13 years of follow-up, PSA screening did not benefit cancer specific mortality.this test cannot be used to evaluate the effect of screening versus not screening, as nearly 90% of men in the control group were tested for PSA.the latest updated data from the ERSPC study estimated that 570 men aged 55 to 69 years were required to be screened in order to prevent one death from prostate cancer during 16 years of follow-up.taking into account the natural history of prostate cancer, a 16 year follow-up period from randomization may not be sufficient to analyze the benefit of screening in terms of mortality, as men usually start screening in their 50s, while the median age of prostate cancer death is 80.this confuses the long-term benefits of guiding policy and patient decision-making with short-term results in clinical trials.among men who were clinically diagnosed with prostate cancer and were followed up for 21 years, the mortality rate of prostate cancer after 15 years was three times that of the previous 15 years.therefore, the long-term absolute benefits of screening may outweigh the benefits observed in the ERSPC study during the 16-year follow-up, as prostate cancer deaths continue to increase.authors point out that screening benefits can not be measured by mortality reduction alone, but also reflect a decrease in incidence rate due to the avoidance of advanced prostate cancer.the relative short-term (12-year) data from four research centers in ERSPC showed that screening reduced the absolute risk of metastatic prostate cancer.the protect study compared the monitoring, surgery, and radiotherapy of locally located prostate cancer, which is mainly low-risk. The results also showed that patients with definite treatment had less prostate cancer metastasis at 10-year follow-up. given the oncological benefits of screening, patients, physicians, and policy makers need to weigh the benefits and risks of screening. the greatest harm may be "over detection" and subsequent long-term treatment-related adverse reactions. although screening must be associated with over detection, many prostate cancer with clinical manifestations may be detected earlier by screening. for example, in ERSPC, the cumulative incidence rate of prostate cancer in the screening group was 13.3% in the 16 years, and 10.3% in the control group, and the relative risk of prostate cancer diagnosed in the screening group decreased compared with the control group with the longer follow-up time. , therefore, the difference in incidence rate is likely to represent the upper limit of overdetection related to screening, because the incidence rate of the control group may continue to catch up with the screening group as the follow-up time goes further. many decision makers now advocate a "common decision" on PSA screening, so patients and physicians must clearly understand the pros and cons of screening. existing prostate cancer screening decision-making aids (such as the US Preventive Services Working Group) and tools developed by the American Academy of family physicians are limited by relying on relatively short-term follow-up data (i.e., 13 years) to calculate the benefits of screening. this reliance on short-term follow-up data is based on an unsubstantiated assumption that the additional benefits of screening will not continue to increase over the lifetime of men. the authors used a formal transparent model to establish a model for the long-term effects of PSA screening. the model predicts that in the United States, in order to prevent one prostate cancer death in 25 years, another 11 cases of prostate cancer need to be diagnosed. although in the ERSPC study, the relative decline in mortality among men diagnosed with prostate cancer during the 16 year screening period remains uncertain, other assumptions supporting the above prediction are conservative. the benefits and risks of other screening programs may vary, while the data on other screening programs from randomized trials are limited. we believe that the above prediction can help us understand the long-term effect of PSA screening more comprehensively. these estimates fail to reflect some important considerations. these considerations include the benefits of avoiding advanced prostate cancer, the costs associated with screening and testing, and the impact of cancer detection and diagnosis on the quality of life of patients. among these concerns about quality of life, the most important one may be that after prostate cancer is detected through screening, men may receive treatment, which may have a long-term impact on urinary and sexual function. editor: Xinya medical journal Public email: yishibao2017@163.com [note] some of the pictures are from the network and wechat circle of friends. 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