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Screening trials are judged on deaths, which take fifteen years to count, and on cancers found, which is the wrong direction. Preventing a man from turning up with cancer already in his bones happens three times as often as preventing a death, arrives years earlier, and is the outcome he cares about.
The 2018 United States task force statement quantifies both: screening men aged 55 to 69 may prevent approximately 1.3 deaths from prostate cancer and approximately 3 cases of metastatic prostate cancer per 1,000 men screened over about 13 years. The metastatic endpoint is more than twice as frequent, and it precedes death by years, so a trial powered on it reads out sooner and smaller. It is also the endpoint that separates the benefit of screening from its harm: overdiagnosis inflates incidence, so incidence is actively misleading, and mortality is confounded by improvements in treatment over the decades a screening trial runs.
Draisma showed that mean lead time is 5.4 to 6.9 years, which is the interval within which a metastatic presentation can be prevented and after which it cannot. The proposal is to adopt the rate of de novo metastatic presentation in the invited population as the primary outcome of any new prostate screening programme or trial, reported per 1,000 invited rather than per 1,000 screened, with prostate cancer mortality as a long-term secondary and incidence reported only as a harm. It is a change in what is measured rather than in what is done, which makes it cheap, and it would let the magnetic resonance imaging-first pathways such as Goteborg-2 be evaluated on a timescale on which policy can actually act.
UK and NHS specifics (the National Screening Committee position, NICE technology appraisals and their recommendation numbers, Cancer Drugs Fund status, magnetic resonance imaging and radiotherapy capacity, National Prostate Cancer Audit indicators and trial access) belong on the UK and NHS page for prostate cancer and are not restated here.
One technology page on OnCo cites this paper by its DOI; this record gives the citation a page of its own so a reader can follow it without leaving OnCo. Read the abstract above alongside the citing page listed under Related; the record was created automatically from the Europe PMC entry and its figures have not been checked by hand.
This is the paper Europe PMC returns for registry id ISRCTN94604465 with the most citations, so it is the natural first reading for anyone following the trial. Read the abstract above alongside the trial page and the registry entry; the record was linked automatically and its figures have not been checked by hand.
The current shape of the screening question in the United States, and the best short statement of the trade-off in numbers a man can weigh. The three-to-one ratio between metastatic cases prevented and deaths prevented is also the argument for using metastatic presentation, not mortality, to judge a screening programme sooner.
The honest state of the overdiagnosis question. Prostate cancer is common in the prostates of men who die of something else, screening finds a proportion of it, and how much of that is harm depends on what is done next. The fix is not a better estimate but fewer treatments for the cancers that do not need them.
The evidence that prostate-specific antigen screening works, stated together with the price. It is the reason screening programmes are debated rather than simply adopted, and the reason every subsequent proposal, from magnetic resonance imaging first to risk-model invitation, is judged on whether it keeps the mortality benefit while reducing the 48.
The reference for anyone quoting an overdiagnosis figure in prostate cancer. The honest statement is a range with its definition and its population attached, and the paper is the reason this page does not print one number.
Shares Prostate-Specific Antigen Screening and 15-Year Prostate Cancer Mortality: A Secondary Analysis of the CAP Randomized Clinical Trial, Lead time, and lead-time bias, Number needed to screen (and number needed to diagnose), ERSPC: screening and prostate cancer mortality in a randomised European study and the tag prostate-evidence.
Shares Lead time, and lead-time bias, ERSPC: screening and prostate cancer mortality in a randomised European study, USPSTF 2018: screening for prostate cancer, recommendation statement (grade C at 55 to 69, grade D at 70 and over), Overtreatment and the tag prostate-evidence.
Shares Lead time, and lead-time bias, Number needed to screen (and number needed to diagnose), ERSPC: screening and prostate cancer mortality in a randomised European study, Early detection roadmap: organ screening → blood tests for many cancers and the tag prostate-evidence.
Shares Lead time and overdiagnosis in prostate-specific antigen screening: importance of methods and context, Lead time, and lead-time bias, Overdiagnosis and overtreatment of prostate cancer, Overtreatment and the tag prostate-evidence.
Shares Prostate Cancer Screening with PSA and MRI Followed by Targeted Biopsy Only, PSA and MRI-first prostate cancer screening, PSA (prostate-specific antigen), Localised prostate cancer, intermediate risk and the tag prostate-evidence.
Shares PSA (prostate-specific antigen), Localised prostate cancer, intermediate risk, Localised prostate cancer, very low and low risk, Localised prostate cancer, high and very high risk and the tag prostate-evidence.
Shares Overtreatment, Overdiagnosis, PSA (prostate-specific antigen), Localised prostate cancer, intermediate risk and the tag prostate-evidence.
Shares MRI-first prostate screening with genetic pre-selection, PSA and MRI-first prostate cancer screening, Localised prostate cancer, intermediate risk, Localised prostate cancer, very low and low risk and the tag prostate-evidence.