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This study presents ground-breaking insights into discontinuing prostate cancer (PCa) screening in previously screened elderly men, aiming to mitigate the risk of overdiagnosis and overtreatment in the face of other-cause mortality. Examining men aged 70–74 who had undergone prostate specific antigen (PSA) based screening, the research followed them until a median age of 88. It noted a significantly lower risk of PCa-specific mortality (PCSM) (0.54% by age 85) compared to the general population (1.9–2.3% by age 85 in Europe / USA). The study found PCSM risks correlated with PSA levels at the last screening, suggesting discontinuation for elderly men with PSA below 3ng/ml, as PCSM was rare (<1%) in this group. While 39% of PCSM events occurred in this group, continuing screening here wouldn’t notably improve outcomes. Histories of benign biopsies were associated with lower PCSM risks. Notably, modern screening methods involving 12-core biopsies and MRI-targeted biopsies could reduce under-sampling and lower PCSM rates further than historical cohorts’ rates. However, discontinuation isn’t risk-free; a small subset may still develop lethal PCa. The research recommends a risk-based approach for continuing screening, considering PSA levels, biopsy history, and comorbidities. Elevated PSA levels without prior biopsies may necessitate continued screening, whereas low PSA levels or hypertension suggest safe discontinuation. Nonetheless, applying specific risk thresholds isn’t advocated; instead, shared decision-making considering individual factors is crucial. Life expectancy estimates of at least 10 years are recommended for screening, supported by a median duration of 13 years between last screening and PCSM. However, solely relying on age for eligibility overlooks vitality, performance status, and treatment willingness. The study’s strengths include long-term follow-up and reliable cause-of-death assessments, yet limitations exist. The use of sextant-core biopsies limits applicability to modern practice, and lack of data post-discontinuation hinders ruling out continued PSA testing’s influence on PCSM rates. Concluding, the study questions the value of ongoing PSA screening for certain elderly men, emphasising a personalised approach considering screening history, comorbidities, and life expectancy. It suggests discontinuation for men with low PSA or benign biopsy history, raising uncertainties about screening in hypertensive elderly men. For men with higher PSA levels without prior biopsies, continued screening may be appropriate if life expectancy exceeds 10 years.

Prostate cancer mortality among elderly men after discontinuing organised screening: long-term results from the European Randomized Study of Screening for Prostate Cancer Rotterdam.
de Vos II, Remmers S, Hogenhout R, Roobol MJ.
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Asif H Ansari

Lewisham and Greenwich NHS Trust.

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