Is 5-year interval sufficient for prostate cancer screening in older men?

Diagnosis, progression, or death due to prostate cancer occur at approximately a decade to 15 years following an initial assessment of prostate-specific antigen (PSA) levels in older men, according to a study presented at EAU 2022.

“Although there is a possibility for men aged >54 years and a baseline PSA level <1.0 ng/mL to be confronted with a diagnosis, to suffer from metastatic disease, and to die from prostate cancer, the risk is very low within a time frame of 2 decades,” said study author Professor Monique Roobol from Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands, and co-authors.

A total of 16,586 men aged 55–69 years were randomized to undergo a 4-year screening protocol between the years 1993 and 1999. Of these, 38 percent (n=6,344) had a baseline PSA level <1.0 ng/mL (3,027 men aged 54–59 years [group A] and 3,317 men aged 60–69 years [group B]).

The men in group A and B were followed up over a median 13.5 and 11.1 years, respectively, during which time 4.5 percent (n=285) were diagnosed with prostate cancer (6.0 and 3.1 percent in group A and B, respectively). Most cases of prostate cancer had a Gleason 6 score. [EAU 2022, abstract A0355]

Overall, 21 cases of prostate cancer (0.3 percent) were metastatic at time of diagnosis and occurred a median 16.1 years following baseline PSA examination, while 18 cases progressed to metastatic disease at a median 4.9 years following diagnosis. 

“In both groups, the time from initial PSA to a diagnosis of clinically significant prostate cancer [2 and 1 percent in group A and B, respectively] was 2–3 times longer than the proposed re-screening interval of 5 years [median 15.7 and 11.7 years for group A and B, respectively],” said the authors.

Among those who had metastatic disease at prostate cancer diagnosis (0.3 and 0.4 percent in group A and B, respectively), metastatic disease was diagnosed at a median 20.6 and 15.6 years following initial PSA in group A and B, respectively. Among those who progressed to metastatic disease (0.2 and 0.3 percent in group A and B, respectively), metastatic disease was diagnosed at a median 4.0 and 5.1 years following diagnosis, respectively.

Metastatic disease was more common among men in group B than group A (22 percent vs 8.8 percent).

After a median 21 years of follow up, 34.4 and 61.8 percent of men in group A and B, respectively, have died, at a median 15.1 and 13.8 years, respectively, since baseline PSA assessment. Of these, eight (0.3 percent) and 15 (0.5 percent) deaths were specifically attributed to prostate cancer, occurring at a median 18.4 and 17.1 years, respectively, since baseline PSA assessment.

“The European Randomised Study of Screening for Prostate Cancer (ERSPC) and other population-based prostate cancer trials show unambiguously that a baseline PSA is indicative for the risk of developing (life-threatening) prostate cancer in the decade(s) to come,” said Roobol and co-authors. “This has important implications for further testing, and it is therefore that most guidelines now recommend a follow-up algorithm based on baseline PSA.”

In 2021, the EAU published a position paper suggesting that in men with low baseline PSA levels, “a 5-year retesting interval or stopping rule for different age groups” could be applied. [Eur Urol 2021;80:703-711]

“[The results of this study show that] the recommended 5-year interval for retesting or even stopping screening in elderly men seems justified when taking into account the considerable harm that coincides with repeated screenings at an elderly age,” the authors concluded.