Toward Improved Prostate Cancer Screening: Insights from the Göteborg-2 Trial

Extract

Long-term outcomes from randomized trials of prostate-specific antigen (PSA)-based prostate cancer screening have shown that regular PSA screening can approximately halve the risk of dying from prostate cancer among men starting PSA testing no later than at age 55. However, screening strategies where elevated PSA triggered biopsy found that a majority of biopsied men had no evidence of cancer and more than half of men with positive biopsies harbored low-grade (International Society of Urological Pathology [ISUP] grade group 1, also called Gleason score 6) prostate cancers with very low likelihood of progression. Moreover, widespread use of radical treatment for men with clinically insignificant tumors unlikely to die from prostate cancer exposed these men to considerable harms from complications and reductions in quality of life associated with those treatments. Over the past decade, broad adoption of active surveillance protocols for men with low-risk prostate cancer has alleviated some concerns about previously rampant overdiagnosis and overtreatment. Active surveillance allows men with low-risk disease to forego upfront radical therapy, with its attendant risks, in lieu of further testing and repeat biopsies. However, active surveillance comes with its own downsides including healthcare system costs from serial follow-up, complications from repeated prostate biopsies, and patient anxiety over perceived nontreatment of active cancer, which is why some patients ultimately proceed with radical therapy even in the absence of disease progression. Hence, there is great interest in identifying ways to avoid diagnosis of ISUP grade 1 disease altogether.