Prostate-Specific Antigen Screening: Time to Change the Dominant Forces on the Pendulum

Whether prostate-specific antigen (PSA) screening prevents men from dying of prostate cancer has been the subject of debate for decades. Rather than resolve the controversy, two major randomized trials of PSA screening, with discrepant results, only further polarized the discussion. We recently showed that PSA testing in the control arm of the major US study, the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, was substantially higher than previously recognized (approximately 90%), making the trial results uninterpretable. Here, we contextualize the debate about PSA screening and highlight the broad implications of our finding for prostate cancer care. Namely, we argue that the remaining singular randomized evidence shows that PSA testing does save lives and that screening should be an evidence-based recommendation. PSA testing was widely adopted in the United States in the early 1990s on the basis of its ability to detect organ-confined prostate cancers. Although population-based screening with PSA clearly resulted in more prostate cancer diagnoses, the morbidity associated with the treatment of indolent disease and the associated costs were major concerns. Randomized controlled trials were therefore initiated in Europe and the United States to address the efficacy of PSA screening. The European study found that PSA screening reduced prostate cancer–specific mortality, whereas the US study, the PLCO Cancer Screening Trial, found no difference in prostate cancer death between the intervention and control arms. 1-3 Based