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Information to Support Informed Choices

Kirsten Howard, BSc(Hons), MAppSc, MPH, MHealthEcon, PhD; Alex Barratt, MBBS, MPH, PhD; Graham J. Mann, MBBS, PhD; Manish I. Patel, MBBS, MMed, FRACS, PhD

Arch Intern Med. 2009;169(17):1603-1610.

Background  Information is needed to aid individual decision making about prostate-specific antigen (PSA) screening.

Methods  We aimed to provide such information for men aged 40, 50, 60, and 70 years at low, moderate, and high risk for prostate cancer. A Markov model compared patients with vs without annual PSA screening using a 20% relative risk (RR) reduction (RR = 0.8) in prostate cancer mortality as a best-case scenario. The model estimated numbers of biopsies, prostate cancers, and deaths from prostate cancer per 1000 men over 10 years and cumulated to age 85 years.

Results  Benefits and harms vary substantially with age and familial risk. Using 60-year-old men with low risk as an example, of 1000 men screened annually, we estimate that 115 men will undergo biopsy triggered by an abnormal PSA screen result and that 53 men will be diagnosed as having prostate cancer over 10 years compared with 23 men diagnosed as having prostate cancer among 1000 unscreened men. Among screened men, 3.5 will die of prostate cancer over 10 years compared with 4.4 deaths in unscreened men. For 1000 men screened from 40 to 69 years of age, there will be 27.9 prostate cancer deaths and 639.5 deaths overall by age 85 years compared with 29.9 prostate cancer deaths and 640.4 deaths overall in unscreened men. Higher-risk men have more prostate cancer deaths averted but also more prostate cancers diagnosed and related harms.

Conclusions  Men should be informed of the likely benefits and harms of PSA screening. These estimates can be used to support individual decision making.

Author Affiliations: Screening and Test Evaluation Program (Dr Howard) and Centre for Medical Psychology and Evidence Based Medicine (Dr Barratt), School of Public Health, and Urological Cancer Surgery (Dr Patel), University of Sydney, Sydney, and Western Clinical School, University of Sydney at Westmead Millennium Institute, Westmead (Dr Mann), Australia.

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