Family history and screening for prostate cancer: no evidence of benefit


In what we believe to be the first report of its kind from anywhere in the world, a new paper has reported that there seems to be no evidence that selective screening of men with a family history of prostate cancer is clinically beneficial compared to men with no family history of prostate cancer.

The paper by Saarimäki et al. in the International Journal of Cancer is based on an analysis of prospectively collected data from the Finnish subset of the European Randomized Study for Screening for Prostate Cancer (the ERSPC trial).

Knowing that family history is one of the few established risk factors for a diagnosis of prostate cancer, the Finnish research team sought to establish the actual impact of family history on outcomes of the Finnish data from the ERSPC. It should be remembered that Finland was the single largest contributor of data to the ERSPC, having enrolled > 80,000 men.

Here are the data as reported by Saarimäki et al.:

  • Within the Finnish data set,
    • 31,866/80,144 men (39.8 percent) were randomized to the screening arm (as opposed to the “usual care” arm) of the trial.
    • These 31,866 men were invited for screening with a PSA test every 4 years (if they had a PSA of < 4 ng/ml).
    • At each screening visit, they were also asked about their family history of prostate cancer.
  • Of the 31,866 men randomized to the screening arm,
    • 23,702 (74.3 percent) invited men actually attending screening clinics.
    • 22,756/23,702 of the attendees (96.0 percent) provided information about their family history.
    • 1,723/23,702 of the attendees (7.3 percent) reported at least one first-degree relative (father or brother) diagnosed with prostate cancer.
    • 235/1,723 men with a first-degree family history of prostate cancer (13.6 percent) were diagnosed with prostate cancer themselves.
  • Men with a first-degree family history of prostate cancer
    • Had an increased risk for diagnosis with prostate cancer themselves (risk ratio [RR] = 1.31, p < 0.001) compared to men with no first-degree family history.
    • Their risk was highest for a diagnosis of intermediate-grade (Gleason 7) prostate cancer (RR = 1.65).
    • Their risk for low-grade (Gleason 2 to 6) tumors was also increased (RR = 1.46).
    • Their risk for high-grade (Gleason 8 to 10 tumors) was significantly decreased (RR = 0.48).
  • The sensitivity and specificity of PSA testing was, overall, slightly inferior for men with a family history of prostate cancer.
  • No difference in prostate cancer-specific mortality was observed among men with a family history of prostate cancer (i.e., getting screened and therefore getting getting diagnosed earlier because of a family history of prostate cancer had no impact on overall survival).

These results come as something of a surprise; arguably, they are even shocking. It has long been assumed that if we could diagnose higher-risk men earlier in the course of their disease, this would significantly improve the likelihood of their long-term survival. Saarimäki et al. appear to have shown that this is not, in fact, the case.

There can be little doubt that members of the U.S. Preventive Services Task Force will see these data as one more justification for their recommendation that mass population-based screening is not justified by the currently available data.

 

One Response

  1. There is a large unknown factor in any analysis to determine higher family risk for prostate cancer-specific mortality and the other measurables; namely, the men who did not know whether their fathers had prostate cancer.

    For many of our father who passed before the early 1990s, we have no idea whether they had prostate cancer or not unless they were symptomatic or died of the disease. This may well account for many of the 21,033 who indicated no family history.

    For me personally, this places a huge question mark on these observations. I would question USPTF if they cited this finding to support their position.

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