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Effect of a low-intensity psa-based screening intervention on prostate cancer mortality : The CAP randomized clinical trial

Published on Mar 6, 2018in JAMA51.27
· DOI :10.1001/jama.2018.0154
Richard M. Martin100
Estimated H-index: 100
(UoB: University of Bristol),
Jenny Donovan79
Estimated H-index: 79
(NIHR: National Institute for Health Research)
+ 23 AuthorsFreddie C. Hamdy67
Estimated H-index: 67
(University of Oxford)
Abstract
Importance Prostate cancer screening remains controversial because potential mortality or quality-of-life benefits may be outweighed by harms from overdetection and overtreatment. Objective To evaluate the effect of a single prostate-specific antigen (PSA) screening intervention and standardized diagnostic pathway on prostate cancer–specific mortality. Design, Setting, and Participants The Cluster Randomized Trial of PSA Testing for Prostate Cancer (CAP) included 419 582 men aged 50 to 69 years and was conducted at 573 primary care practices across the United Kingdom. Randomization and recruitment of the practices occurred between 2001 and 2009; patient follow-up ended on March 31, 2016. Intervention An invitation to attend a PSA testing clinic and receive a single PSA test vs standard (unscreened) practice. Main Outcomes and Measures Primary outcome: prostate cancer–specific mortality at a median follow-up of 10 years. Prespecified secondary outcomes: diagnostic cancer stage and Gleason grade (range, 2-10; higher scores indicate a poorer prognosis) of prostate cancers identified, all-cause mortality, and an instrumental variable analysis estimating the causal effect of attending the PSA screening clinic. Results Among 415 357 randomized men (mean [SD] age, 59.0 [5.6] years), 189 386 in the intervention group and 219 439 in the control group were included in the analysis (n = 408 825; 98%). In the intervention group, 75 707 (40%) attended the PSA testing clinic and 67 313 (36%) underwent PSA testing. Of 64 436 with a valid PSA test result, 6857 (11%) had a PSA level between 3 ng/mL and 19.9 ng/mL, of whom 5850 (85%) had a prostate biopsy. After a median follow-up of 10 years, 549 (0.30 per 1000 person-years) died of prostate cancer in the intervention group vs 647 (0.31 per 1000 person-years) in the control group (rate difference, −0.013 per 1000 person-years [95% CI, −0.047 to 0.022]; rate ratio [RR], 0.96 [95% CI, 0.85 to 1.08]; P  = .50). The number diagnosed with prostate cancer was higher in the intervention group (n = 8054; 4.3%) than in the control group (n = 7853; 3.6%) (RR, 1.19 [95% CI, 1.14 to 1.25]; P P P  = .49). In the instrumental variable analysis for prostate cancer mortality, the adherence-adjusted causal RR was 0.93 (95% CI, 0.67 to 1.29; P  = .66). Conclusions and Relevance Among practices randomized to a single PSA screening intervention vs standard practice without screening, there was no significant difference in prostate cancer mortality after a median follow-up of 10 years but the detection of low-risk prostate cancer cases increased. Although longer-term follow-up is under way, the findings do not support single PSA testing for population-based screening. Trial Registration ISRCTN Identifier:ISRCTN92187251
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  • References (36)
  • Citations (43)
References36
Newest
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#2Susan J. Curry (UI: University of Iowa)H-Index: 34
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#2Matthew R. Cooperberg (UCSF: University of California, San Francisco)H-Index: 52
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#1Grace Young (UoB: University of Bristol)H-Index: 5
#2Sean Harrison (UoB: University of Bristol)H-Index: 6
Last.Chris Metcalfe (UoB: University of Bristol)H-Index: 37
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#1Alex TsodikovH-Index: 39
#2Roman Gulati (Fred Hutchinson Cancer Research Center)H-Index: 28
Last.Ruth Etzioni (Fred Hutchinson Cancer Research Center)H-Index: 48
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#1Kirsten Bibbins-Domingo (UCSF: University of California, San Francisco)H-Index: 51
#2David C. Grossman (KP: Kaiser Permanente)H-Index: 18
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#1Hashim U. Ahmed (UCL: University College London)H-Index: 46
#2Ahmed El-Shater Bosaily (UCL: University College London)H-Index: 4
Last.Mark Emberton (UCL: University College London)H-Index: 63
view all 14 authors...
#1Sigrid Carlsson (MSK: Memorial Sloan Kettering Cancer Center)H-Index: 24
#2Melissa Assel (MSK: Memorial Sloan Kettering Cancer Center)H-Index: 11
Last.Hans Lilja (University of Oxford)H-Index: 78
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#1Eleanor Walsh (UoB: University of Bristol)H-Index: 9
#2Emma L Turner (UoB: University of Bristol)H-Index: 14
Last.Richard M. Martin (UoB: University of Bristol)H-Index: 100
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Cited By43
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#2Marcel Hanna (UEA: University of East Anglia)
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#2César Capera-López (National University of Colombia)
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#2Amanda Black (NIH: National Institutes of Health)H-Index: 33
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