Comparative efficiency of prostate-specific antigen screening strategies for prostate cancer detection

Context Despite widespread use of serum prostate-specific antigen (PSA) tes ting to detect prostate cancer, the relative effectiveness of different PSA screening strategies is unknown. Objective To compare prostate cancer mortality, PSA testing rates, and biop sy rates using various PSA screening strategies, including the standard str ategy of annually testing men aged 50 through 75 years. Design and Setting A Monte-Carlo simulation based on a Markov model was use d to simulate the natural history of prostate cancer using different starti ng ages, testing intervals, and PSA thresholds for prostate biopsy. Age-spe cific PSA levels and prostate biopsy detection probabilities were determine d from population data and surgical series. Main Outcome Measures Numbers of prevented prostate cancer deaths, PSA test s, and prostate biopsies per 1000 men aged 40 through 80 years, compared am ong 7 different strategies vs no screening. Results Compared with annual PSA testing beginning at age 50 years, the str ategy of PSA testing at ages 40 and 45 years followed by biennial testing b eginning at age 50 years was estimated to simultaneously reduce prostate ca ncer mortality and number of PSA tests and biopsies performed per 1000 men. Specifically, compared with no screening, the standard strategy prevents 3 .2 deaths, with an additional 10500 PSA tests and 600 prostate biopsies, wh ile the earlier but less frequent strategy prevents 3.3 deaths, with an add itional 7500 PSA tests and 450 prostate biopsies. Strategies that lowered t he PSA threshold for prostate biopsy to below 4.0 ng/mL or strategies that used age-specific PSA levels were not more efficient than use of a PSA thre shold of 4.0 ng/mL, These 2 findings remained true under all sensitivity an alyses performed to test assumptions of the model, Conclusion Recognizing that the efficacy of PSA screening is unproved, the standard strategy of annual PSA screening beginning at age 50 years appears to be less effective and more resource intensive compared with a strategy that begins earlier but screens biennially instead of annually.