Special article
Prostate-specific antigen screening for prostate cancer in males older than 75 years
Cribado del cáncer de próstata con antígeno específico prostático en varones mayores de 75 años
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In fact, its use has been catapulted indiscriminately throughout the developed world, even years before the results of large randomised clinical trials were known, and sometimes without considering the characteristics of the population where this intervention was applied.</p><p id="par0025" class="elsevierStylePara elsevierViewall">This review article analyses the pros and cons of screening for PC in asymptomatic male patients, specifically focusing on the population aged over 75.</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, three randomised clinical trials have been carried out, notable for their quality, follow-up time and sample size (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). They are based on the prospective and long-term comparison of the causes of death between the two areas of study (randomisation): intervention (where PSA determination, prostate biopsy and treatment in the detected PC are carried out) and control (where only deaths and their causes are investigated, without testing). It is worth noting that none of these studies recruited a population aged over 75.<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">–</span><p id="par0035" class="elsevierStylePara elsevierViewall">The Prostate, Lung, Colorectal, and Ovarian Screening Trial (PLCO),<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a> in the USA studied a total of 76,685 males recruited after a median follow-up of 13 years. No significant reduction in mortality due to PC was observed.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">–</span><p id="par0040" class="elsevierStylePara elsevierViewall">Eight European countries, including Spain, participated in the European Randomized Study of Screening for Prostate Cancer (ERSPC).<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a> It recruited 182,160 males. After 13 years’ follow-up, a reduction in mortality by PC of 21% was observed due to screening. Each death prevented – which would have been caused by PC – required the screening of 781 patients, of which 27 will be diagnosed with PC (and most probably treated).</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">–</span><p id="par0045" class="elsevierStylePara elsevierViewall">The Cluster Randomized Trial of PSA Testing for Prostate Cancer (CAP),<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a> carried out in the United Kingdom. A total of 415,357 males were included. The intervention comprised a single visit with determination of PSA. After a median follow-up of ten years, no significant difference in PC mortality was observed between the two areas under study.</p></li></ul></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">As we can see, ‘everything that glitters is not gold’. In the only study where screening reduced the risk of dying from PC,<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a> this reduction came at a considerable cost: that of overdetection. We could define it as the diagnosis of tumours without clinical relevance (and which would thus have little impact on the patient's life). Overdetection is obviously accompanied by overtreatment (with the consequent risk of adverse effects and impact on quality of life). It has been estimated that up to 40–50% of PCs detected by screening could be included in this category.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">7,9</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">None of the studies mentioned has shown a reduction in mortality from all causes. In other words, screening can prevent deaths by PC, but it would not be correct to say that it ‘saves lives’. The main objective of these studies is to reduce mortality from PC, and to do so they have had to be designed with a sample size of more than 180,000 participants.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">10</span></a> However, a much more operational objective would be the reduction of global mortality, since it would avoid biases such as those introduced by the adverse effects of treatments, as well as the incorrect assignment of causes of death. Some authors even question the mere approach of these large studies.<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 11.8%, but only 2.6% of dying from this cause (after more than 30 years’ follow-up),<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">12</span></a> and our aim was a hypothetical reduction in global mortality, we would need a sample size of millions of participants.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a> Firstly: a study of such proportions would be unfeasible. Second: 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. And all this in a population without limitations in their life expectancy.</p><p id="par0060" class="elsevierStylePara elsevierViewall">As we can see, the use of PC screening as a method to reduce mortality from this disease is still controversial, even in a younger population. It should be added that none of the clinical trials conducted has included a population aged over 75, so there are no results to support its use in this population.</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.</p><p id="par0070" class="elsevierStylePara elsevierViewall">It should be noted that although both treatments have similar oncological results,<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">13</span></a> radical prostatectomy does have a greater overall survival compared to observation without treatment, although eight patients must undergo surgery to prevent one death. Furthermore, benefits in terms of survival does not occur in patients over 65.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">14</span></a> For this reason, offering intensive treatments to patients who have a limited life expectancy does not seem to make much sense.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">‘Lead time’, natural history of prostate cancer and life expectancy</span><p id="par0075" class="elsevierStylePara elsevierViewall">‘Lead time’ is the time between the detection of PC by screening until the time it would have been detected for other reasons. It is actually a bias to consider lead times in survival studies, since that period could be interpreted as providing a greater survival for tumours diagnosed by screening, when what really occurs is simply that the diagnosis is ‘moved forward’. It is also a measure of the natural history of the disease. In the ERSPC study<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a> this interval was calculated at eight years (average) for males aged 65–74. If to those eight years we add the estimated time from diagnosis to death by PC, the resulting figure far exceeds the 10–15 years of life expectancy that a patient should have before screening or any intensive treatment for this disease is given.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Life expectancy is an equation that is calculated using two factors: age<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>comorbidities. It can be calculated intuitively (at a guess) in cases where it is very evident, or with the help of calculators. The Charlson Comorbidity Index (1987)<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> assigns a score based on the patient's age and medical history. Online calculators are available that offer mortality (probability) after one year using this scale.</p><p id="par0085" class="elsevierStylePara elsevierViewall">In Spain, the National Institute of Statistics (INE) offers tables and life expectancy projections based on age, sex and other parameters.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a> Latest data (2017) show that the life expectancy of a 65-year-old man in our country is 19.1 years. In the INE projection tables, life expectancy for men aged 75 ranges between 11.8 years (2016) and 12.2 years (2020).<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.<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">–</span><p id="par0095" class="elsevierStylePara elsevierViewall">US Preventive Services Task Force (USPSTF). Organism that regulates Preventive Medicine in the USA. Since 2011, this body has recommended not screening the asymptomatic male population,<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">18,19</span></a> which has led to a significant decrease in the incidence of PC in the USA over the last few years. In April 2017, this body reviewed its recommendation – moving towards it being more the patient's decision – after studying the pros and cons in the male population aged between 55 and 69.<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a> All scientific societies advocate this ‘informed and shared decision’. None of the reports published by the USPSTF in recent years recommend screening for PC in men over 75.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">–</span><p id="par0100" class="elsevierStylePara elsevierViewall">European Association of Urology (EAU-ESTRO-SIOG). This entity suggests allowing for ‘informed decisions’ in potential patients.<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> They propose that screening should be stopped after a certain age, but do not specify it. They indicate that this age should be based on life expectancy (where age and comorbidities are taken into account). Furthermore, they admit that it is unlikely that men with less than 15 years of life expectancy will benefit from screening.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">–</span><p id="par0105" class="elsevierStylePara elsevierViewall">American Cancer Society (ACS), USA. This organisation does not recommend routine screening for any age group. It advocates for ‘informed decisions’ for patients who have at least 10 years’ life expectancy after information about the uncertainties, risks and benefits of screening are given.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">–</span><p id="par0110" class="elsevierStylePara elsevierViewall">National Comprehensive Cancer Network (NCCN), USA. This entity recommends screening, although always after the benefits and risks of determination of PSA are discussed. Unlike other scientific societies, it recommends screening in men older than 75, although it also recommends that this is carried out only in cases with very good health and little or no comorbidity.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a></p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">–</span><p id="par0115" class="elsevierStylePara elsevierViewall">American Association of Urology (AUA), USA. This entity recommends offering screening (informed decision) to males aged between 55 and 69, but discourages its use outside this age range due to the absence of available evidence.<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. For this reason, they recommend discussing the pros and cons of screening for PC with the patient. In other words, they agree on the importance of reaching an ‘informed shared decision’, although it is undeniable that there is a practical difficulty for this, especially in Primary Care. In practice, there are many barriers, such as limited time before care must be provided, patients’ demands, different perspectives between professionals, fear of litigation, etc.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a> In addition, due to the limited benefit of PC screening (at best) according to available evidence,<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">6–8</span></a> some professionals consider it as absurd as discussing the benefits and risks of using antibiotics for viral infections, or as requesting magnetic resonance imaging for patients with uncomplicated acute lower back pain.</p><p id="par0125" class="elsevierStylePara elsevierViewall">In short, most scientific societies recommend its use in the population with a minimum life expectancy of 10–15 years. Except for some isolated case, they do not recommend its use in men older than 75.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Use of prostate-specific antigen in elderly population. The crude reality</span><p id="par0130" class="elsevierStylePara elsevierViewall">As we have indicated before, none of the large randomised studies have included a population of over 75.<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">6–8</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">However, we have indirect evidence of the screening performance in this population. The Baltimore Longitudinal Study of Aging (BLSA) study carried out in the USA showed that no participant aged between 75 and 80 with a PSA level less than 3.0<span class="elsevierStyleHsp" style=""></span>ng/ml died of prostate cancer.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">26</span></a> In view of these data, it is possible to definitively and safely interrupt screening with PSA in elderly patients with PSA levels within normal limits.</p><p id="par0140" class="elsevierStylePara elsevierViewall">The harsh reality is that, although practically no scientific society recommends the use of PSA in the elderly population, the use of this marker is very common in elderly patients. In the USA, PSA screening is carried out in 44.3% of men whose age ranges between 75 and 80.<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a> Another study with 500,000 American veterans found that up to 56% of men over 70 underwent the PSA test in 2003, and that their health status was not taken into account when this decision was made.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">In Spain, the rate of PSA screening is not only frequent in men aged over 70, but it is also higher in younger age groups. It seems that at least one annual PSA is performed in 46% of men aged between 70 and 80, and in 36% of those aged over 80.<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a> Another study showed that the PSA sampling rate in the general population is 21.6/1000 persons per year, 86.8 are aged between 55 and 69 and 152.6 in males aged >70 (21% of those exposed over a two-year period).<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, but its frequency of use is considerable. However, according to current evidence, it should not be recommended in this population group. Even in the male population that has more than 10 years’ life expectancy, screening for PC is still controversial due to the imbalance between the potential benefits and the risks that it presents, 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.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Results of randomised clinical trials" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Results of treatment for prostate cancer" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "‘Lead time’, natural history of prostate cancer and life expectancy" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Recommendations from certain scientific societies" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Use of prostate-specific antigen in elderly population. The crude reality" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Conclusions" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflict of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-07-09" "fechaAceptado" => "2018-08-01" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Luján M, Páez Á. Cribado del cáncer de próstata con antígeno específico prostático en varones mayores de 75 años. Med Clin (Barc). 2019;152:237–240.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">PC: prostate cancer.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \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 \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 \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 \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 \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 \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 (median) \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 \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 \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 \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 \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, Lung, Colorectal, and Ovarian Screening Trial \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">USA<br>(multicentre) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">76,685 (age 55–74) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1:1 intervention compared to control \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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 years \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 (relative increase of 12%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \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.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a> \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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Europe (multicentre, eight countries) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">182,160 (age 50–74) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1:1 intervention compared to control \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Screening every 1–4 years with PSA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21% reduction in the risk of dying from PC<br>For each death due to PC prevented, 781 men are screened and 27 of them are diagnosed with PC. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \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.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a> \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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">United Kingdom (multicentre) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">415,357 (age 50–69) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1:1 intervention compared to control \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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 years \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 (4.3%) compared to control (3.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \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.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1985698.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Summary of the results of the main randomised studies into PC screening.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \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 \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 \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 \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 \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 \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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">USA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">‘Informed decision’ (discuss pros and cons) for the population aged between 55 and 69 \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 >75 \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.<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a> \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 (EAU-ESTRO-SIOG) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Europe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">‘Informed decision’ (discuss pros and cons) for potential patients \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 <15 years \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.<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> \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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">USA \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. In interested males with >10 years’ life expectancy, ‘informed decision’ (discuss pros and cons) \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 <10 years \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.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> \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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">USA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Recommends screening, ‘informed decision’ (discuss pros and cons) for potential patients \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 >5, although it also recommends that this is carried out only in cases with ‘very good health and little or no comorbidity’ \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> \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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">USA \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 (‘informed decision’) to males aged between 55 and 69 \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 (<55 and >69) \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.<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">24</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1985697.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Recommendations from different scientific societies regarding prostate cancer screening.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib0155" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cancer statistics, 2018" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R.L. 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