Prostate-specific antigen screening for prostate cancer in males older than 75 years

Luján, Marcos; Páez, Álvaro
doi:10.1016/j.medcle.2018.08.013
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since the asymptomatic male population began to be screened for PC with serum prostate-specific antigen &#40;PSA&#41; determination on a massive scale at the beginning of the 1990s&#44; there has been a considerable increase in its incidence rate&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> And in the same vein&#44; a change in the stage of PC at the time of diagnosis has been observed&#44; with a greater detection of tumours at an early stage &#40;confined to the organ&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a> thus making it potentially curable&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Based on these data&#44; we could conclude that the benefits of screening for PC are indisputable&#46; In fact&#44; its use has been catapulted indiscriminately throughout the developed world&#44; even years before the results of large randomised clinical trials were known&#44; and sometimes without considering the characteristics of the population where this intervention was applied&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">This review article analyses the pros and cons of screening for PC in asymptomatic male patients&#44; specifically focusing on the population aged over 75&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Results of randomised clinical trials</span><p id="par0030" class="elsevierStylePara elsevierViewall">To date&#44; three randomised clinical trials have been carried out&#44; notable for their quality&#44; follow-up time and sample size &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; They are based on the prospective and long-term comparison of the causes of death between the two areas of study &#40;randomisation&#41;&#58; intervention &#40;where PSA determination&#44; prostate biopsy and treatment in the detected PC are carried out&#41; and control &#40;where only deaths and their causes are investigated&#44; without testing&#41;&#46; It is worth noting that none of these studies recruited a population aged over 75&#46;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8211;</span><p id="par0035" class="elsevierStylePara elsevierViewall">The Prostate&#44; Lung&#44; Colorectal&#44; and Ovarian Screening Trial &#40;PLCO&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a> in the USA studied a total of 76&#44;685 males recruited after a median follow-up of 13 years&#46; No significant reduction in mortality due to PC was observed&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8211;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Eight European countries&#44; including Spain&#44; participated in the European Randomized Study of Screening for Prostate Cancer &#40;ERSPC&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a> It recruited 182&#44;160 males&#46; After 13 years&#8217; follow-up&#44; a reduction in mortality by PC of 21&#37; was observed due to screening&#46; Each death prevented &#8211; which would have been caused by PC &#8211; required the screening of 781 patients&#44; of which 27 will be diagnosed with PC &#40;and most probably treated&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8211;</span><p id="par0045" class="elsevierStylePara elsevierViewall">The Cluster Randomized Trial of PSA Testing for Prostate Cancer &#40;CAP&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a> carried out in the United Kingdom&#46; A total of 415&#44;357 males were included&#46; The intervention comprised a single visit with determination of PSA&#46; After a median follow-up of ten years&#44; no significant difference in PC mortality was observed between the two areas under study&#46;</p></li></ul></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">As we can see&#44; &#8216;everything that glitters is not gold&#8217;&#46; In the only study where screening reduced the risk of dying from PC&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a> this reduction came at a considerable cost&#58; that of overdetection&#46; We could define it as the diagnosis of tumours without clinical relevance &#40;and which would thus have little impact on the patient&#39;s life&#41;&#46; Overdetection is obviously accompanied by overtreatment &#40;with the consequent risk of adverse effects and impact on quality of life&#41;&#46; It has been estimated that up to 40&#8211;50&#37; of PCs detected by screening could be included in this category&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">7&#44;9</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">None of the studies mentioned has shown a reduction in mortality from all causes&#46; In other words&#44; screening can prevent deaths by PC&#44; but it would not be correct to say that it &#8216;saves lives&#8217;&#46; The main objective of these studies is to reduce mortality from PC&#44; and to do so they have had to be designed with a sample size of more than 180&#44;000 participants&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">10</span></a> However&#44; a much more operational objective would be the reduction of global mortality&#44; since it would avoid biases such as those introduced by the adverse effects of treatments&#44; as well as the incorrect assignment of causes of death&#46; Some authors even question the mere approach of these large studies&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a> If we consider that a 50-year-old male in the USA has a risk of being diagnosed with a PC throughout his life of 11&#46;8&#37;&#44; but only 2&#46;6&#37; of dying from this cause &#40;after more than 30 years&#8217; follow-up&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">12</span></a> and our aim was a hypothetical reduction in global mortality&#44; we would need a sample size of millions of participants&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a> Firstly&#58; a study of such proportions would be unfeasible&#46; Second&#58; you do not have to be an expert in statistics to realise that the differences that are sought in studies that need a massive sample size are often very small&#46; And all this in a population without limitations in their life expectancy&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">As we can see&#44; the use of PC screening as a method to reduce mortality from this disease is still controversial&#44; even in a younger population&#46; It should be added that none of the clinical trials conducted has included a population aged over 75&#44; so there are no results to support its use in this population&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Results of treatment for prostate cancer</span><p id="par0065" class="elsevierStylePara elsevierViewall">Treatments with curative intent for PC that have proven efficiency in terms of survival are radical prostatectomy and external prostatic radiotherapy&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">It should be noted that although both treatments have similar oncological results&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">13</span></a> radical prostatectomy does have a greater overall survival compared to observation without treatment&#44; although eight patients must undergo surgery to prevent one death&#46; Furthermore&#44; benefits in terms of survival does not occur in patients over 65&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">14</span></a> For this reason&#44; offering intensive treatments to patients who have a limited life expectancy does not seem to make much sense&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">&#8216;Lead time&#8217;&#44; natural history of prostate cancer and life expectancy</span><p id="par0075" class="elsevierStylePara elsevierViewall">&#8216;Lead time&#8217; is the time between the detection of PC by screening until the time it would have been detected for other reasons&#46; It is actually a bias to consider lead times in survival studies&#44; since that period could be interpreted as providing a greater survival for tumours diagnosed by screening&#44; when what really occurs is simply that the diagnosis is &#8216;moved forward&#8217;&#46; It is also a measure of the natural history of the disease&#46; In the ERSPC study<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a> this interval was calculated at eight years &#40;average&#41; for males aged 65&#8211;74&#46; If to those eight years we add the estimated time from diagnosis to death by PC&#44; the resulting figure far exceeds the 10&#8211;15 years of life expectancy that a patient should have before screening or any intensive treatment for this disease is given&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Life expectancy is an equation that is calculated using two factors&#58; age<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>comorbidities&#46; It can be calculated intuitively &#40;at a guess&#41; in cases where it is very evident&#44; or with the help of calculators&#46; The Charlson Comorbidity Index &#40;1987&#41;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> assigns a score based on the patient&#39;s age and medical history&#46; Online calculators are available that offer mortality &#40;probability&#41; after one year using this scale&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">In Spain&#44; the National Institute of Statistics &#40;INE&#41; offers tables and life expectancy projections based on age&#44; sex and other parameters&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a> Latest data &#40;2017&#41; show that the life expectancy of a 65-year-old man in our country is 19&#46;1 years&#46; In the INE projection tables&#44; life expectancy for men aged 75 ranges between 11&#46;8 years &#40;2016&#41; and 12&#46;2 years &#40;2020&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Recommendations from certain scientific societies</span><p id="par0090" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> outlines the recommendations of certain European and US scientific societies&#46;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8211;</span><p id="par0095" class="elsevierStylePara elsevierViewall">US Preventive Services Task Force &#40;USPSTF&#41;&#46; Organism that regulates Preventive Medicine in the USA&#46; Since 2011&#44; this body has recommended not screening the asymptomatic male population&#44;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">18&#44;19</span></a> which has led to a significant decrease in the incidence of PC in the USA over the last few years&#46; In April 2017&#44; this body reviewed its recommendation &#8211; moving towards it being more the patient&#39;s decision &#8211; after studying the pros and cons in the male population aged between 55 and 69&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a> All scientific societies advocate this &#8216;informed and shared decision&#8217;&#46; None of the reports published by the USPSTF in recent years recommend screening for PC in men over 75&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8211;</span><p id="par0100" class="elsevierStylePara elsevierViewall">European Association of Urology &#40;EAU-ESTRO-SIOG&#41;&#46; This entity suggests allowing for &#8216;informed decisions&#8217; in potential patients&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> They propose that screening should be stopped after a certain age&#44; but do not specify it&#46; They indicate that this age should be based on life expectancy &#40;where age and comorbidities are taken into account&#41;&#46; Furthermore&#44; they admit that it is unlikely that men with less than 15 years of life expectancy will benefit from screening&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8211;</span><p id="par0105" class="elsevierStylePara elsevierViewall">American Cancer Society &#40;ACS&#41;&#44; USA&#46; This organisation does not recommend routine screening for any age group&#46; It advocates for &#8216;informed decisions&#8217; for patients who have at least 10 years&#8217; life expectancy after information about the uncertainties&#44; risks and benefits of screening are given&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8211;</span><p id="par0110" class="elsevierStylePara elsevierViewall">National Comprehensive Cancer Network &#40;NCCN&#41;&#44; USA&#46; This entity recommends screening&#44; although always after the benefits and risks of determination of PSA are discussed&#46; Unlike other scientific societies&#44; it recommends screening in men older than 75&#44; although it also recommends that this is carried out only in cases with very good health and little or no comorbidity&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a></p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8211;</span><p id="par0115" class="elsevierStylePara elsevierViewall">American Association of Urology &#40;AUA&#41;&#44; USA&#46; This entity recommends offering screening &#40;informed decision&#41; to males aged between 55 and 69&#44; but discourages its use outside this age range due to the absence of available evidence&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">24</span></a></p></li></ul></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">All scientific societies are aware of the current controversy regarding the benefits and risks of screening&#46; For this reason&#44; they recommend discussing the pros and cons of screening for PC with the patient&#46; In other words&#44; they agree on the importance of reaching an &#8216;informed shared decision&#8217;&#44; although it is undeniable that there is a practical difficulty for this&#44; especially in Primary Care&#46; In practice&#44; there are many barriers&#44; such as limited time before care must be provided&#44; patients&#8217; demands&#44; different perspectives between professionals&#44; fear of litigation&#44; etc&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a> In addition&#44; due to the limited benefit of PC screening &#40;at best&#41; according to available evidence&#44;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">6&#8211;8</span></a> some professionals consider it as absurd as discussing the benefits and risks of using antibiotics for viral infections&#44; or as requesting magnetic resonance imaging for patients with uncomplicated acute lower back pain&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In short&#44; most scientific societies recommend its use in the population with a minimum life expectancy of 10&#8211;15 years&#46; Except for some isolated case&#44; they do not recommend its use in men older than 75&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Use of prostate-specific antigen in elderly population&#46; The crude reality</span><p id="par0130" class="elsevierStylePara elsevierViewall">As we have indicated before&#44; none of the large randomised studies have included a population of over 75&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">6&#8211;8</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">However&#44; we have indirect evidence of the screening performance in this population&#46; The Baltimore Longitudinal Study of Aging &#40;BLSA&#41; study carried out in the USA showed that no participant aged between 75 and 80 with a PSA level less than 3&#46;0<span class="elsevierStyleHsp" style=""></span>ng&#47;ml died of prostate cancer&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">26</span></a> In view of these data&#44; it is possible to definitively and safely interrupt screening with PSA in elderly patients with PSA levels within normal limits&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The harsh reality is that&#44; although practically no scientific society recommends the use of PSA in the elderly population&#44; the use of this marker is very common in elderly patients&#46; In the USA&#44; PSA screening is carried out in 44&#46;3&#37; of men whose age ranges between 75 and 80&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a> Another study with 500&#44;000 American veterans found that up to 56&#37; of men over 70 underwent the PSA test in 2003&#44; and that their health status was not taken into account when this decision was made&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">In Spain&#44; the rate of PSA screening is not only frequent in men aged over 70&#44; but it is also higher in younger age groups&#46; It seems that at least one annual PSA is performed in 46&#37; of men aged between 70 and 80&#44; and in 36&#37; of those aged over 80&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a> Another study showed that the PSA sampling rate in the general population is 21&#46;6&#47;1000 persons per year&#44; 86&#46;8 are aged between 55 and 69 and 152&#46;6 in males aged &#62;70 &#40;21&#37; of those exposed over a two-year period&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclusions</span><p id="par0150" class="elsevierStylePara elsevierViewall">Routine screening with PSA in the asymptomatic population aged older than 75 is not only carried out in clinical practice&#44; but its frequency of use is considerable&#46; However&#44; according to current evidence&#44; it should not be recommended in this population group&#46; Even in the male population that has more than 10 years&#8217; life expectancy&#44; screening for PC is still controversial due to the imbalance between the potential benefits and the risks that it presents&#44; especially in terms of overdetection</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflict of interest</span><p id="par0155" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Luj&#225;n M&#44; P&#225;ez &#193;&#46; Cribado del c&#225;ncer de pr&#243;stata con ant&#237;geno espec&#237;fico prost&#225;tico en varones mayores de 75 a&#241;os&#46; Med Clin &#40;Barc&#41;&#46; 2019&#59;152&#58;237&#8211;240&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Medullary&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Scope&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sample size&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Randomisation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Follow-up time &#40;median&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Results&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mortality difference due to PC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Global mortality difference&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Reference&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prostate&#44; Lung&#44; Colorectal&#44; and Ovarian Screening Trial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">USA<br>&#40;multicentre&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">76&#44;685 &#40;age 55&#8211;74&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#58;1 intervention compared to control&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Annual screening with PSA and digital rectal examination&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Greater detection of PC in intervention &#40;relative increase of 12&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Andriole et al&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">European Randomized Study of Screening for Prostate Cancer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Europe &#40;multicentre&#44; eight countries&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">182&#44;160 &#40;age 50&#8211;74&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#58;1 intervention compared to control&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Screening every 1&#8211;4 years with PSA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21&#37; reduction in the risk of dying from PC<br>For each death due to PC prevented&#44; 781 men are screened and 27 of them are diagnosed with PC&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Schroder et al&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cluster Randomised Trial of PSA Testing for Prostate Cancer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">United Kingdom &#40;multicentre&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">415&#44;357 &#40;age 50&#8211;69&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#58;1 intervention compared to control&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A single determination of PSA at the start of the study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Greater detection of PC in intervention &#40;4&#46;3&#37;&#41; compared to control &#40;3&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Martin et al&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Scientific society&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Scope&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Recommendation for the population susceptible to screening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Recommendation for elderly patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Reference&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">US Preventive Services Task Force&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">USA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8216;Informed decision&#8217; &#40;discuss pros and cons&#41; for the population aged between 55 and 69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not recommended for those aged &#62;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grossman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">European Association of Urology &#40;EAU-ESTRO-SIOG&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Europe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8216;Informed decision&#8217; &#40;discuss pros and cons&#41; for potential patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not recommended if life expectancy is &#60;15 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mottet et al&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">American Cancer Society&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">USA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">This organisation does not recommend routine screening for any age group&#46; In interested males with &#62;10 years&#8217; life expectancy&#44; &#8216;informed decision&#8217; &#40;discuss pros and cons&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not recommended if life expectancy is &#60;10 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Wolf et al&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">National Comprehensive Cancer Network&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">USA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Recommends screening&#44; &#8216;informed decision&#8217; &#40;discuss pros and cons&#41; for potential patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Recommends screening in some men &#62;5&#44; although it also recommends that this is carried out only in cases with &#8216;very good health and little or no comorbidity&#8217;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NCCN<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">American Association of Urology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">USA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Recommends offering it &#40;&#8216;informed decision&#8217;&#41; to males aged between 55 and 69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not recommended in other age ranges &#40;&#60;55 and &#62;69&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Carter et al&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">24</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Recommendations from different scientific societies regarding prostate cancer screening&#46;</p>"
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