ERSPC Summary

Routine Prostate Screening Reduces Mortality
The European Randomized Screening for Prostate Cancer Study: A Summary
Colin Rice, Prostate Cancer Awareness Grant Coordinator
Planned Parenthood of Amarillo and the Texas Panhandle
8 October, 2008 

Prostate cancer is a leading cause of cancer deaths in much of the industrialized, western world.1 There are many different speculations as to the cause of higher incidence and mortality rates in western countries, ranging from dietary factors such as high animal fat intake and a sedentary lifestyle to biological factors, as indicated by the higher mortality among African Americans and Caucasians when compared to their peers of Hispanic or Oriental descent.2 Many countries in Europe have begun an aggressive and highly documented and analyzed campaign to promote prostate screening, and the plethora of results published indicate that there is, indeed, a benefit to routine screening.

      The European Randomized Screening for Prostate Cancer (ERSPC) compiled results from across the European continent, from countries such as Sweden, Austria and the Netherlands. The structure of the ERSPC study, as seen in Aus' work, took a sample of the male population that was at risk for prostate cancer as determined by their age. All men between the ages of 50 and 64 at the beginning of the study were considered ‘at risk.' The total at risk population in Sweden was 32,298, and 20,000 of these men were randomly assigned to form to groups at a 1:1 ratio. After excluding 55 men who had already been diagnosed with prostate cancer, two groups were formed: a control group of 9973 men who were not actively screened, and an experimental group of 9972. Of the experimental group, 7516 responders received PSA measurement every second year, and 2456 were non-responders.3 the study took place over ten years in Sweden, beginning in 1995. Their results, summarized in the table below, analyze different aspects of cancer progression and treatment in the 810 cases of prostate cancer diagnosed in the screening arm, and the 442 cases diagnosed in the control arm.3 While men in the active screening group had an incidence rate 1.8 times higher than in the control, they saw their risk of being diagnosed with high-grade, metastatic cancer reduced by 49.8 percent.3 Of the 810 diagnoses in the screening group, 24 cases were advanced prostate cancer; 13 of these 24 cases occurred within the 2456 non-respondents.3 The cancer diagnosed in men in the screening group predominantly Your browser may not support display of this image.represented localized, early-stage cancer.3  Patients who are diagnosed with early stages of disease have been shown to have decreased mortality rate, making early and active screening a beneficial tactic in preventing a treatable disease from becoming terminal.3 Men in the screening group

    Screening Arm (n=810) Control Arm (n=442)
T Stage      
T1   567 210
T2   197 160
T3   27 45
T4   9 15
Tx   10 12
Gleason Score      
3 to 4   7 10
5 to 6   635 223
7   121 124
8 to 10   29 43
Gx   18 42
PSA (ng/ml)      
Mean (median)   19.8 (4.8) 90.4 (9.9)
PSA Levels      
0-4 ng/ml   277 43
4-10 ng/ml   370 176
10-20 ng/ml   88 99
20-50 ng/ml   45 65
50-100 ng/ml   9 17
>100 ng/ml   14 37
Unknown   7 5
Primary Treatment      
Expectancy   309 150
Radical prostatectomy   335 150
Radiotherapy   74 59
Hormonal Therapy   56 93
Other   36 39

were also less likely to exhibit high-risk features of prostate cancer, including an overall lower prostate volume and lower PSA levels. 3

Similar results were found in other branches of the ERSPC study. The branch of the study conducted in Rotterdam, the Netherlands, consistently found that, under the same methods, only 7 patients from the screening group were diagnosed with metastatic disease, compared with 27 in the control group.4 A similarly constructed Quebecois study infers lower mortality in men who are actively screened; and yet another early detection program carried out in the state of Tirol, Austria, credits the combination of early screening and availability of treatments with a 33% reduction in prostate cancer mortality when compared to the rest of the country.5,6

Your browser may not support display of this image. Many doctors are hesitant to routinely screen their at-risk patients for prostate cancer, and some commonly cited excuses are the lack of research proving its necessity and the associated cost of widespread screening. While continuing research by the ERSPC validates the preventative benefits of active screening, an independent Swedish study was performed analyzing the costs associated with diagnosing early prostate cancer.

Screening Round 1 2 3 4 Total
Cost per detected cancer* 160800 128000 126200 117400 137900
Cost per potentially curative treatment* 254600 639900 820100 352300 370100

This study found that the average cost per case of prostate cancer that was diagnosed early was 37% of the cost of a case of prostate cancer that developed and required potentially curative treatment at time of diagnosis.7 Incorporating this active screening with shared decision making on the part of the doctor and patient can greatly reduce the financial and health burdens presented by prostate cancer by enabling both the doctor and the patient to make proactive decisions to control the disease in its early stages.

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Works Cited

  1. Morky B, Risser D, Williams MA, Weiss NS (eds.). "Prostate Cancer in Texas 2006." Austin, TX: Department of State Health Services. December, 2006.
  2. Gaston, Kris E; Pruthi, Raj S. "Racial Differences in Prostate Cancer." North Carolina Medical Journal, vol 6 no 2, March/April 2006.
  3. Aus, Gunnar; Bergdahl, Svante; Lodding, Pär, et al. "Prostate Cancer Screening Decreases the Absolute Risk of Being Diagnosed with Advanced Prostate Cancer-Results from a Prospective, Population-Based Randomized Controlled Trial." European Urology 2007;51:659-664
  4. van der Cruisjen-Koeter IW; Vis AN; Roobol MJ, et al. "Comparison of Screen Detected and Clinically diagnosed Prostate Cancer in the European Randomized Study of Screening for Prostate Cancer, section Rotterdam." J Urology 2005; 174:121-5.
  5. Labrie F; Candas B; Dupont A, et al. "Screening Decreases Prostate Cancer Death: First Analysis of the 1988 Quebec Prospective Randomized Controlled Trial." Prostate 1999; 38:83-91.
  6. Bartsch G; Horninger W; Klocker H, et al. "Prostate Cancer Mortality after Introduction of Prostate-Specific Antigen Mass Screening in the Federal State of Tyrol, Austria." Urology 2001; 58:417-24.
  7. Holmberg H; Carlsson P; Löfman O; Varenhorst E. "Economic Evaluation of Screening for Prostate Cancer: A Randomized Population Based Programme during a 10-yr Period in Sweden." Health Policy 1998;45:133-147.