Prostate-specific antigen (PSA) screening has been shown to reduce prostate cancer mortality by 13% over a median follow-up of 23 years, according to the latest analysis from the European Randomized Study of Screening for Prostate Cancer (ERSPC). Published in The New England Journal of Medicine, the study also indicates an improved balance between the benefits of screening and the potential harms of overdiagnosis and overtreatment.
Originally launched in 1993, the ERSPC was designed to determine whether systematic, population-based PSA screening could lower deaths from prostate cancer. Earlier results at 16 years suggested a 20% relative reduction in mortality; however, this benefit was offset by the detection of tumors unlikely to cause symptoms or death, raising concerns about overtreatment.
Updated ERSPC Findings After 23 Years
The updated analysis included 162,236 men, aged 55 to 69 at the study’s start, from eight European countries. Participants were randomly assigned to either a screening group (72,888 men offered repeated PSA testing) or a control group (89,348 men who did not receive screening offers). On average, men in the screening group underwent two PSA tests over the follow-up period.
After 23 years, the cumulative incidence of prostate cancer was 14% in the screening group compared with 12% in the control group, reflecting a risk ratio of 1.30. More importantly, cumulative prostate cancer mortality was 1.4% in the screening group versus 1.6% in the control group, corresponding to a risk ratio of 0.87. The absolute risk reduction increased to 0.22% from 0.14% at the 16-year mark.
The study authors highlighted that, at 23 years, one death from prostate cancer was prevented for every 456 men invited for screening and for every 12 men diagnosed with prostate cancer. This represents an improvement compared with 16-year follow-up data, where one death was prevented per 628 invitations and per 18 diagnoses, confirming sustained long-term benefits of PSA testing.
Balancing Screening Benefits and Risks
While the study confirms that PSA screening lowers prostate cancer mortality, the research team emphasized the importance of weighing these benefits against potential harms. Limitations of the study include population differences, protocol variations, and the exclusion of lower-quality French data. Moreover, PSA testing outside the study was not fully tracked, potentially underestimating the benefits of screening.
Advances in diagnostics and treatment since the study began may also influence the relevance of these findings today, though they could enhance the overall value of PSA screening. The authors cautioned that overdiagnosis and unnecessary interventions remain significant concerns.
To optimize outcomes, future strategies should prioritize risk-based PSA screening, targeting men most likely to benefit while minimizing unnecessary procedures. This approach could maintain the long-term mortality reduction observed in the ERSPC while reducing harm.
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