Alberto Donzelli

Gianluca Castelluzzo

Giulia Giudicatti

English

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EURURO-8514; No. of Pages 2Letter to the EditorE U R O P E A N U R O L O G Y X X X ( 2 0 1 9 ) X X X – X X Xava i lable at www.sc iencedirect .comjourna l homepage: www.europea nurology.comRe: Jonas Hugosson, Monique J. Roobol, MarianneMånsson, et al. A 16-yr Follow-up of the EuropeanRandomized Study of Screening for Prostate Cancer.Eur Urol 2019;76:43–51Mortality in the Age Group 70 yr and the Case of ItalyIn their paper on prostate cancer (PCa) mortality andprostate-specific antigen (PSA) screening, Hugosson et al [1]conclude “Findings corroborate earlier results that PSAscreening significantly reduces PCa mortality, showinglarger absolute benefit with longer follow-up and areduction in excess incidence. Repeated screening may beimportant to reduce PCa mortality on a population level.”The patient summary states “ . . . repeated screeningreduces the risk of dying from prostate cancer”.Although both messages are formally correct, wedisagree with their implications, resulting in a boost tomeasure PSA more often at the population level, regardlessof age.First, the rate ratio for PCa mortality was 0.80 at 16 yr, but anumber of males, and maybe some doctors, might misun-derstand, translating this to a 20% lower all-cancer mortality(or greatly overestimate the benefit in terms of cancer-specific mortality [2]) or even all-cause mortality. We knowthat PSA screening does not reduce all-cause mortality [3] andthe ERSPC trial reconfirms this (rate ratio for all ages 0.99, 95%confidence interval [CI] 0.98–1.01) [1]. Why would a manaspire to not die from PCa if he understands that he could diefrom some other cause without any increase in his lifeexpectancy? Indeed, in a randomized trial [4] primary carepatients received an informed consent statement thatincluded, among other information, “There is no evidencethat having the test allows men to lead longer lives . . . ”(reconfirmed some 20 yr later) [1]. Informed men were muchless likely to show high interest in screening (odds ratio 0.34,95% CI 0.19–0.60) [4].Second, all-cause and PCa mortality are not equallydistributed: for men outside the core age group (summingages 50–54 and 70 yr), published data allow calculation ofa rate ratio of 1.0052171, which represents a nonsignificantincrease in all-cause mortality. In the age group 70 yr, evenPCa mortality tended to increase, with a rate ratio of 1.06[1]. A strong message should be to stop screening men aged70 yr rather than perform PSA testing more often.Please cite this article in press as: Donzelli A, et al. Re: Jonas HuFollow-up of the European Randomized Study of Screening for Prodoi.org/10.1016/j.eururo.2019.07.045https://doi.org/10.1016/j.eururo.2019.07.0450302-2838/© 2019 European Association of Urology. Published by Elsevier BThird, the data for Italy are particularly alarming. Among14 515 participants over median follow-up of 15 yr, the PCamortality rate ratio was 0.99 (95% CI 0.66–1.49), the numberneeded to invite to screening to prevent one PCa death was44 232, and the number needed to detect PCa to prevent onePCa death was 673 [1], with a highly significant increase inPCa incidence, and thus in tests, visits, surgical, radio-therapeutic, and hormonal interventions, health conse-quences, and costs, without an overall benefit. Thesedisappointing results (and the concept of all-cause mortali-ty) should be clearly communicated to the population.Indeed, Italian males undergo PSA testing more frequentlythan women undergo mammography, although healthauthorities do not officially recommend PSA screening.Fourth, the patient summary not only reiterates long-standing problems for complete informed consent but alsoundermines the opportunity costs. Decision-makers shouldconsider the net results of any allocative intervention(treatment of men overdiagnosed via screening). The harmsof displacing equivalent resources that could be used forother cost-effective interventions should also be deducted(and it is unlikely that PSA screening can be considered cost-effective, especially in the Italian health system).There are many underused interventions for men’shealth with low costs per QALY that could be consideredbefore promoting PSA screening. For example, a motiva-tional interview or exercise prescription to increase physicalactivity [5] or a 5-min brief intervention plus self-help forsmoking cessation [5] are at best orders of magnitude lessexpensive per QALY than very questionable screening.Conflicts of interest: The authors have nothing to disclose.References[1] Hugosson J, Roobol MJ, Månsson M, Tammela TLJ, Zappa M, Nelen V.16-yr follow-up of the European randomized study of screening forprostate cancer. Eur Urol 2019;76:43–51.[2] Domenighetti G, D’Avanzo B, Egger M, Berrino F, Perneger T, Mos-coni P. Women’s perception of the benefits of mammographyscreening: population-based survey in four countries. Int J Epide-miol 2003;32:816–21.[3] Saquib N, Saquib J, Ioannidis JPA. Does screening for disease savelives in asymptomatic adults? Systematic review of meta-analysesand randomized trials. Int J Epidemiol 2015;44:264–77.[4] Wolf AMD, Nasser JF, Wolf AM, Schorling JB. The impact of informedconsent on patient interest in prostate-specific antigen screening.Arch Intern Med 1996;156:1333–6.gosson, Monique J. Roobol, Marianne Månsson, et al. A 16-yrstate Cancer. Eur Urol 2019;76:43–51. Eur Urol (2019), https://.V. All rights reserved.E U R O P E A N U R O L O G Y X X X ( 2 0 1 9 ) X X X – X X X2EURURO-8514; No. of Pages 2[5] Owen L, Morgan A, Fischer A, Ellis S, Hoy A, Kelly MP. The cost-effectiveness of public health interventions. J Publ Health2012;34:37–45.Alberto Donzellia*Gianluca CastelluzzobGiulia GiudicattibPlease cite this article in press as: Donzelli A, et al. Re: Jonas HuFollow-up of the European Randomized Study of Screening for Prodoi.org/10.1016/j.eururo.2019.07.045aFondazione Allineare Sanità e Salute, Milan, ItalybDepartment of Hygiene, Public Health and Preventive Medicine, Universityof Milano-Bicocca, Milan, Italy*Corresponding author. Fondazione Allineare Sanità e Salute, Via CarloGiuseppe Merlo 3, Milan 20122, Italy.E-mail address: adonzelli1@libero.it (A. Donzelli).gosson, Monique J. Roobol, Marianne Månsson, et al. A 16-yrstate Cancer. Eur Urol 2019;76:43–51. Eur Urol (2019), https://

Re: Jonas Hugosson, Monique J. Roobol, Marianne Månsson, et al. A 16-yr Follow-up of the European Randomized Study of Screening for Prostate Cancer. Eur Urol 2019;76:43-51: Mortality in the Age Group ≥70 yr and the Case of Italy.

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Re: Jonas Hugosson, Monique J. Roobol, Marianne Månsson, et al. A 16-yr Follow-up of the European Randomized Study of Screening for Prostate Cancer. Eur Urol 2019;76:43-51: Mortality in the Age Group ≥70 yr and the Case of Italy.

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