title: Estimating the impact on prostate cancer mortality of incorporating prostate-specific antigen testing into screening.
abstract: OBJECTIVE
  Whether early detection using prostate-specific antigen (PSA) and digital rectal examination (DRE) compared with DRE alone will reduce prostate cancer mortality awaits the results of ongoing prospective randomized trials. However, the impact that early detection could have on prostate cancer-specific survival can be estimated by assuming that PSA failure after radical prostatectomy (RP) will translate into death from prostate cancer.
  
  
  METHODS
  The study population consisted of 1274 men with clinically localized prostate cancer who underwent RP in Boston, Massachusetts or Philadelphia, Pennsylvania between 1989 and 2000 and had a preoperative PSA level greater than 4 but not more than 10 ng/mL. The primary endpoint was actuarial freedom from PSA failure (defined as PSA outcome).
  
  
  RESULTS
  The relative risk of PSA failure after RP for patients diagnosed with a PSA of greater than 4 to 5, 5 to 6, 6 to 7, or 7 to 8 ng/mL compared with greater than 8 up to 10 ng/mL was 0.3 (95% confidence interval [CI] 0.2 to 0.5), 0.5 (95% CI 0.4 to 0.8), 0.6 (95% CI 0.4 to 0.9), or 0.9 (95% CI 0.6 to 1.3), respectively. On the basis of the estimates of the 5-year PSA outcome, patients with a biopsy Gleason score of 5 or 6 (781 of 1274; 61%) consistently benefited from RP performed when the PSA at diagnosis was greater than 4 to 7 ng/mL compared with greater than 8 to 10 ng/mL (93% versus 78%, P <0.0001). A benefit to early detection was not found for the vast majority (266 of 312; 88%) of patients who had a biopsy Gleason score of 7 or higher.
  
  
  CONCLUSIONS
  Early detection using both PSA and DRE-based screening may benefit men who present with biopsy Gleason score 5 or 6 prostate cancer and a PSA level greater than 4 to 7 ng/mL compared with greater than 8 up to 10 ng/mL. This finding awaits validation from ongoing prospective randomized trials.
authors.affiliation: Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, Massachusetts 02215, USA.
authors.forename: A V
authors.initials: AV
authors.lastname: D'Amico
authors.forename: R
authors.initials: R
authors.lastname: Whittington
authors.forename: S B
authors.initials: SB
authors.lastname: Malkowicz
authors.forename: A A
authors.initials: AA
authors.lastname: Renshaw
authors.forename: J E
authors.initials: JE
authors.lastname: Tomaszewski
authors.forename: C
authors.initials: C
authors.lastname: Bentley
authors.forename: D
authors.initials: D
authors.lastname: Schultz
authors.forename: S
authors.initials: S
authors.lastname: Rocha
authors.forename: A
authors.initials: A
authors.lastname: Wein
authors.forename: J P
authors.initials: JP
authors.lastname: Richie
mesh_terms: D000206:Actuarial Analysis; D000328:Adult; D000368:Aged; D016009:Chi-Square Distribution; D018572:Disease-Free Survival; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D010173:Palpation / Q000706:statistics & numerical data; D016016:Proportional Hazards Models; D011467:Prostate / Q000473:pathology / Q000601:surgery; D017430:Prostate-Specific Antigen / Q000097:blood*; D011468:Prostatectomy; D011471:Prostatic Neoplasms / Q000401:mortality* / Q000473:pathology / Q000601:surgery; D012189:Retrospective Studies; D016019:Survival Analysis; D016896:Treatment Outcome
chemical_list: D017430:Prostate-Specific Antigen