This is not the most recent version of the article. View current version (31 JAN 2013)
Screening for prostate cancer
Editorial Group: Cochrane Prostatic Diseases and Urologic Cancers Group
Published Online: 8 OCT 2008
Assessed as up-to-date: 9 JUN 2009
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
How to Cite
Ilic D, O'Connor D, Green S, Wilt TJ. Screening for prostate cancer. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD004720. DOI: 10.1002/14651858.CD004720.pub2.
- Publication Status: Edited (no change to conclusions)
- Published Online: 8 OCT 2008
This is not the most recent version of the article.View current version (31 Jan 2013)
Any form of screening aims to reduce disease specific and overall mortality and improve a person's future quality of life. Screening for prostate cancer has generated considerable debate within the medical and broader community, as demonstrated by the varying recommendations made by medical organizations and governed by national policies. Much of this debate is due to the limited availability of high quality research and the influence of false-positive or false-negative results generated by use of the screening techniques such as the digital rectal examination (DRE) and prostate-specific antigen (PSA) blood test. Our 2006 Cochrane review identified insufficient evidence to either support, or refute, the use of routine mass, selective or opportunistic screening for prostate cancer. This article is an update of that review.
To determine whether screening for prostate cancer reduces prostate cancer-specific mortality, all-cause mortality, and its impact on quality of life, including adverse events.
An updated search of electronic databases (PROSTATE register, CENTRAL the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CANCERLIT and the NHS EED) was performed, in addition to hand searching of specific journals and bibliographies in an effort to identify both published and unpublished trials.
All randomised controlled trials (RCTs) of screening versus no screening for prostate cancer were eligible for inclusion in this review.
Data collection and analysis
The original search (2006) identified 99 potentially relevant articles that were selected for full text review. From these citations, two RCTs were identified as meeting the inclusion criteria. In this updated version of the review, the updated search identified a further 106 potentially relevant articles. From these 106 citations, a further 3 RCTs were identified as meeting the inclusion criteria. Data from the trials were independently extracted by two authors.
Five RCTs with a total of 341,351 participants were included in this review. All involved PSA testing, though the interval and threshold for further evaluation varied across trials. The age of participants ranged from 50 to 74 years and duration of follow up from 7 to15 years. The methodological quality of three of the studies was assessed as posing a high risk of bias. Our analysis of the five studies showed no statistically significant reduction in prostate cancer-specific or all-cause mortality among the whole population of men randomised to screening versus controls. A preplanned analysis of a 'core' age group of men aged 55 to 69 from the largest trial (ERSPC) reported a significant 20% relative reduction in prostate cancer-specific mortality; (95% CI 0.65 to 0.98) (ARR = 0.71 per 1000 men). Meta-analysis of the five included studies indicated no statistically significant difference in prostate cancer-specific mortality between men randomised to screening and control (RR 0.95, CI 0.85 to 1.07). Sub-group analyses indicated that prostate cancer-specific mortality was not affected by age at which participants were screened. Meta-analysis of two studies investigating all-cause mortality did not determine any significant differences between men randomised to screening or control (RR 1.00, 95% CI 0.98 to 1.02). A diagnosis of prostate cancer was significantly greater in men randomised to screening, compared to those randomised to control (RR 1.35, 95% CI 1.06 to 1.72). None of the studies provided detailed assessment of the effect of screening on quality of life or costs associated with screening. Harms of screening included high rates of false-positive results for the PSA test (up to 75.9%), over-diagnosis (up to 50% in the ERSPC study) and adverse events associated with transrectal ultrasound (TRUS) guided biopsies such as infection, bleeding and pain.
Prostate cancer screening did not significantly decrease prostate cancer-specific mortality in a combined meta-analysis of five RCTs. Only one study (ERSPC) reported a benefit in a subgroup of men aged 55 to 69. Within this subgroup of men it was determined that 1410 men needed to be invited to screening and 48 additional men subsequently diagnosed with prostate cancer needed to receive early intervention to prevent one additional prostate cancer death at 10 years. Men should be informed of this and the demonstrated adverse effects when deciding whether or not to undertake screening for prostate cancer. Any benefits from prostate cancer screening may take up to 10 years to accrue; therefore, men who have a life expectancy less than 10 to 15 years should be informed that screening for prostate cancer is unlikely to be beneficial.
Plain language summary
Screening for prostate cancer
Prostate cancer is one of the most prevalent forms of cancer in men worldwide. Screening for prostate cancer requires diagnostic tests to be performed in the absence of any symptoms or indications of disease. These tests include the digital rectal examination (DRE), the prostate-specific antigen (PSA) blood test and the transrectal ultrasound-guided biopsy (TRUS). Screening aims to identify cancers at an early and treatable stage, therefore increasing the chances of successful treatment while also improving a patient's future quality of life. This review identified five relevant studies, comprising of 341,351 participants in total. Two of the studies were assessed to be of low risk of bias, whilst the remaining three had methodological weaknesses. Meta-analysis of the five included studies demonstrated no statistically significant reduction in prostate cancer-specific mortality (RR 0.95, 95% CI 0.85 to 1.07). Only a preplanned analysis of a 'core' age group of men from the largest study included in this review reported a significant 20% relative reduction in prostate cancer-specific mortality. Among this 'core' group of men aged 55 to 69 the ERSPC authors report that 1410 men would need to be screened to prevent one additional death from prostate cancer during a 9-year period, which is also associated with 48 men needing to be treated for prostate cancer (RR 0.80, 95% CI 0.65 to 0.98). Harms included high rates of false-positive results for the PSA test (up to 75.9%), infection, bleeding, and pain associated with subsequent biopsy.
任何一種篩檢的目的都是為了減少死亡率及提升生活品質。而至目前為止前列腺癌篩檢在醫學界引起相當多的爭議，因為醫學團體和官方的全國性政策各有不同的建議所致。大部份的爭議是由於可利用的高品質研究資料有限，及各種診斷方法所產生的偽陽性或偽陰性的結果，例如肛門指診 (digital rectal examination, DRE) 和前列腺特異抗原 (prostate specific antigen, PSA) 血液檢查。
搜尋電子資料庫 (如：PROSTATE register，CENTRAL the Cochrane Central Register of Controlled Trials，MEDLINE, EMBASE，CANCERLIT and the NHS EED)、人工搜尋特定期刊以及書目，藉此找出出版或未出版的試驗。
2組隨機對照試驗總共有55,512 人參與，但是這2試驗的方法學上都有缺點。 使用篩檢意願 (intentiontoscreen) 和統合分析 (metaanalysis) 重新分析這二組隨機對照試驗，發現篩檢試驗組及對照組在前列腺癌死亡率，並無顯著的統計上差異 (RR 1.01，95% CI: 0.80−1.29)。至目前為止沒有相關研究評估前列腺癌篩檢於生活品質、全原因死亡率及成本效益上的成效。
此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。
在全世界，前列腺癌是男性最常見的癌症之一。在沒有任何症狀之下，前列腺癌的篩檢需要診斷的工具，這些工具包括肛門指診檢查 (DRE)，前列腺特異抗原 (PSA) 和經直腸超音波導引下 (TRUS) 前列腺切片檢查。篩檢的目的在早期發現，增加成功治療的機會，並維持生活品質，這2篇臨床試驗各包含了9,026位和46,486位受試者，然而，2篇都不算是高品質的文章，所以並沒有高水準的證據，去支持到底要不要做前列腺癌篩檢，以及經由DRE、PSA及經直腸超音波導引下前列腺切片，是否比完全不做篩檢可降低前列腺癌的死亡人數。至於因篩檢而影響生活品質及金錢花費方面，這2篇臨床試驗完全沒有探討，有另外2個大型的臨床試驗，將會在未來幾年完成，就可以對這議題提供更多的資訊。