背景:前列腺特异性抗原(PSA)检测在前列腺癌(PCa)筛查中的作用近几十年来随着多项随机对照试验(RCT)促使指南的改变而不断发展。目前,由于许多前列腺癌的惰性性质以及过度诊断和过度治疗的相关风险,存在争议.这篇综述审查了评估PSA筛查的主要RCT,以告知临床实践。
方法:我们总结了从主要RCT调查PSA筛查对PCa死亡率和发病率的影响的结果:前列腺,肺,结肠直肠,和卵巢癌(PLCO)筛查试验,欧洲前列腺癌筛查随机研究(ERSPC),和前列腺癌PSA检测(CAP)的集群随机试验。
结果:PLCO试验将男性随机接受每年PSA和DRE筛查或常规治疗,报告17岁时各组间PCa死亡率无显著差异(RR0.93,[95%CI:0.81-1.08]),然而,在筛查组中,格里森6(RR1.17,[95%CI:1.11-1.23])和8-10疾病(RR0.89,[95%CI:0.80-0.99])的检测显着增加,同时检测降低,分别。ESPRC试验将7个欧洲国家的男性随机进行PSA筛查,每2-4年或常规治疗。注意到9年时PCa死亡率降低20%(RR0.81,[95%CI:0.65-0.98]),12年时转移性疾病显著降低(RR0.70,[95%CI:0.60-0.82]).CAP试验评估了单一PSA筛查试验对PCa死亡率的影响,结果在10年时PCa死亡率无显著差异(RR0.96,[95%CI:0.85-1.08])。研究的局限性包括研究组之间的高度污染和对研究方案的低依从性。
结论:虽然CAP和最初的PLCO试验显示PCa死亡率没有显著降低,ERSPC在13年时减少了21%,在延长随访中进一步受益。结果的差异归因于试验设计的变化,污染,坚持率,PSA阈值。未来的研究需要集中在优化筛查间隔上,针对高危人群,并纳入非侵入性诊断工具,以提高筛查效果并减少相关危害。
BACKGROUND: The role of prostate-specific antigen (PSA) testing in prostate cancer (PCa) screening has evolved over recent decades with multiple randomized controlled trials (RCTs) spurring guideline changes. At present, controversy exists due to the indolent nature of many prostate cancers and associated risks of overdiagnosis and overtreatment. This review examines major RCTs evaluating PSA screening to inform clinical practices.
METHODS: We summarize findings from primary RCTs investigating PSA screening\'s impact on PCa mortality and incidence: the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, the European Randomized Study of Screening for Prostate Cancer (ERSPC), and the Cluster Randomized Trial of PSA Testing for Prostate Cancer (
CAP).
RESULTS: The PLCO Trial randomized men to annual PSA and DRE screening or usual care, reporting no significant difference in PCa mortality between groups at 17 years (RR 0.93, [95% CI: 0.81-1.08]), yet significantly increased detection and concomitant decreased detection in Gleason 6 (RR 1.17, [95% CI: 1.11-1.23]) and 8-10 disease (RR 0.89, [95% CI: 0.80-0.99]) in the screening group, respectively. The ESPRC Trial randomized men across seven European countries to PSA screening every 2-4 years or usual care, noting a 20% reduction in PCa mortality at 9 years (RR 0.81, [95% CI: 0.65-0.98]) and significant decrease in metastatic disease at 12 years (RR 0.70, [95% CI: 0.60-0.82]). The
CAP Trial assessed a single PSA screening test\'s impact on PCa mortality yielding no significant difference in PCa mortality at 10 years (RR 0.96, [95% CI: 0.85-1.08]). Limitations amongst studies included high contamination between study arms and low compliance with study protocols.
CONCLUSIONS: While the
CAP and initial PLCO trials showed no significant reduction in PCa mortality, the ERSPC demonstrated a 21% reduction at 13 years, with further benefits at extended follow-up. Differences in outcomes are attributed to variations in trial design, contamination, adherence rates, and PSA thresholds. Future studies are needed focus on optimizing screening intervals, targeting high-risk populations, and incorporating non-invasive diagnostic tools to improve screening efficacy and reduce associated harms.