Prostate cancer mortality after introduction of prostate-specific antigen mass screening in the Federal State of Tyrol, Austria

doi:10.1016/S0090-4295(01)01264-X

Urology

Volume 58, Issue 3, September 2001, Pages 417-424

https://doi.org/10.1016/S0090-4295(01)01264-X Get rights and content

Abstract

Objectives. To monitor the impact of screening in a natural experiment by comparing prostate cancer mortality in Tyrol, where prostate-specific antigen (PSA) testing was introduced at no charge, with the rest of Austria, where it was not introduced.

Methods. In 1993, PSA testing was made freely available to men aged 45 to 75 years in the Federal State of Tyrol, Austria. At least two thirds of all men in this age range have been tested at least once during the first 5 years of the study. Initially, only total PSA was measured, but free PSA measurement was added in 1995. The IMX assay was used. Digital rectal examination was not part of the screening examination.

Results. Significant migration to lower stages has been observed since the introduction of this screening program. A reduction in mortality rates in the rest of Austria from 1993 onward has occurred, with the reduction in Tyrol much greater; the mortality remained fairly constant between 1993 and 1995 and subsequently fell. The trends in prostate cancer mortality rates since 1993 differ significantly between Tyrol (P = 0.006) and the rest of Austria. On the basis of the age-specific death rates averaged from 1986 to 1990, the difference between the number of expected and observed deaths from prostate cancer in Tyrol was 22 in the group aged 40 to 79 years in 1998 and 18 the following year.

Conclusions. These findings are consistent with the hypothesis that the policy of making PSA testing freely available, and the wide acceptance by men in the population, is associated with a reduction in prostate cancer mortality in an area in which urology services and radiotherapy are available freely to all patients. It is our opinion that most of this decline is likely to be due to aggressive downstaging and successful treatment and that any contribution from detecting and treating early cancers will only become apparent in the years to come.

Section snippets

Material and methods

In 1993, a mass screening project using PSA as the only screening test was launched in the Federal State of Tyrol (one of the nine federal states of the Republic of Austria). Previously (1988 to 1992), both PSA and the digital rectal examination (DRE) were available and used in the diagnostic workup of patients with suspected prostate cancer and in a limited way for asymptomatic men. Since 1989, urologists at the Innsbruck University Hospital have promoted the concept of prostate cancer early

Results

During 1993, when PSA testing became freely available, 32.3% of Tyrollean men between 45 and 75 years old underwent PSA screening, and more than two thirds of this population were tested at least once during the first 5 years of the study. At the laboratory of the Department of Urology, Innsbruck University, more than 76,000 men were screened at least once. Of these, 7100 were aged 45 to 49 years and 2900 were aged 40 to 44 years. Thus, a substantial number of men aged 40 to 44 were screened,

Comment

Three possibilities could lead to a reduction in the mortality rate from prostate cancer: (a) prevention of the disease, (b) detection of the disease at a stage when it is more likely to be curable, and (c) improvement in the outcome of therapy for metastatic disease. A fourth possibility, that screening would bring forward the time of death in some individuals, is very unlikely to explain the differences observed. Currently, screening for prostate cancer is in a phase of rapid development,

Acknowledgements

To Dipl.Kfm. Heinz Öhler, Director of the Tiroler Gebietskrankenkasse, and Dipl.Vw. Max Laimböck, Director of Innsbruck University Hospital for their generous support and to the colleagues and staff of the Osterreichisches Statistiches Zentral AMT (Austrian Federal Office for Statistics) in Vienna for their collaboration; and to several independent scientists and, in particular, Dr. Otis Brawley, Dr. Freda Alexander, and Dr. Philippe Autier, for their advice and comments.

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Evaluate the impact on QoL attributable to the treatment for Organ Confined Prostate Cancer (OCPC).
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Prostate cancer is among the most prevalent cancers worldwide and is the third most common cause of cancer-associated mortality among men [1]. While the introduction of PSA-screening has led to earlier diagnosis of prostate cancer [2], a subset of patients develops high-risk or metastatic disease. Radiographic diagnostic studies are critical in the evaluation of these patients, particularly in assessing the presence of metastatic disease before definitive treatment or disease recurrence following treatment.
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Los programas de cribado de cáncer de próstata basados en la determinación sérica del antígeno específico de próstata han llevado a un sobrediagnóstico y, como consecuencia, a un sobretratamiento. Un porcentaje de varones diagnosticados de cáncer de próstata tienen un tumor que no progresará o lo hará lentamente (sobrediagnóstico o pseudoenfermedad). Esta tasa de sobrediagnóstico oscila entre el 17-50%.
El cribado poblacional se define como la exploración sistemática de hombres asintomáticos. La detección precoz o cribado oportunista conlleva la búsqueda de casos individuales, siendo iniciada por el médico o el propio paciente. Ante un paciente que acuda a consulta solicitando un antígeno específico de próstata se le deben explicar una serie de cuestiones relativas al sobrediagnóstico, el sobretratamiento y los posibles daños derivados de la biopsia.
Con los datos de los estudios aleatorizados sobre el antígeno específico de próstata y el cribado de cáncer de próstata, ninguna sociedad urológica recomienda realizar cribado poblacional.
Screening programs for prostate cancer based on the determination of serum prostate specific antigen has led to overdiagnosis, and consequently overtreatment. A percentage of men diagnosed with prostate cancer have a tumour that will not progress, or do so slowly (overdiagnosis or pseudo-disease). This overdiagnosis rate ranges from 17-50%.
Mass screening is defined as the systematic examination of asymptomatic men. Early detection or opportunistic screening involves the pursuit of individual cases being initiated by the doctor or the patient. In the case of a patient who requests a prostate specific antigen from their general practitioner, a number of issues on overdiagnosis, over-treatment and possible damage from the biopsy, should be explained to him.
With data from randomised studies on prostate specific antigen and prostate cancer screening, population screening is not recommended by any urological society.

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^☆: This project was partially funded within the framework of support from the Associazione Italiana per la Ricera sul Cancro (Italian Association for Research on Cancer).

¹: This work was conducted within the framework of an Agreement for Co-operation in Urological Oncology between the Division of Epidemiology and Biostatistics of the European Institute of Oncology and the Department of Urology of the University of Innsbruck.

²: A complete list of the Tyrol Prostate Cancer Screening Group is provided in the .

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Adult urologyProstate cancer mortality after introduction of prostate-specific antigen mass screening in the Federal State of Tyrol, Austria1☆,

Abstract

Section snippets

Material and methods

Results

Comment

Acknowledgements

J Urol

J Urol

J Urol

Urology

Urology

Urology

Ann Oncol

Lancet

Patterns of care for carcinoma of the prostate glandresults of a national survey of 1984 and 1990

J Am Coll Surg

Screening for prostate canceran analysis of the early experience

CA Cancer J Clin

PSA based screening for prostate cancer in asymptomatic younger malespilot study in blood donors

Prostate

Frequency and clinical significance of transition zone cancer in prostate cancer screening

Prostate

Improvement of specificity in PSA based screening by using PSA transition zone density and percent free PSA in addition to total PSA levels

Prostate

Serum prostate specific antigen in a community-based population of healthy menestablishment of age specific reference ranges

JAMA

Adult urology
Prostate cancer mortality after introduction of prostate-specific antigen mass screening in the Federal State of Tyrol, Austria¹☆,