Overdiagnosis and overtreatment of prostate cancer

Stacy Loeb, Marc A. Bjurlin, Joseph Nicholson, Teuvo L. Tammela, David F. Penson, H. Ballentine Carter, Peter Carroll, Ruth Etzioni

Research output: Contribution to journalReview article

330 Citations (Scopus)

Abstract

Context Although prostate cancer (PCa) screening reduces the incidence of advanced disease and mortality, trade-offs include overdiagnosis and resultant overtreatment. Objective To review primary data on PCa overdiagnosis and overtreatment. Evidence acquisition Electronic searches were conducted in Cochrane Central Register of Controlled Trials, PubMed, and Embase from inception to July 2013 for original articles on PCa overdiagnosis and overtreatment. Supplemental articles were identified through hand searches. Evidence synthesis The lead-time and excess-incidence approaches are the main ways used to estimate overdiagnosis in epidemiological studies, with estimates varying widely. The estimated number of PCa cases needed to be diagnosed to save a life has ranged from 48 down to 5 with increasing follow-up. In clinical studies, generally lower rates of overdiagnosis have been reported based on the frequency of low-grade minimal tumors at radical prostatectomy (1.7-46.8%). Autopsy studies have reported PCa in 18.5-38.5%, although not all are low grade or low volume. Factors influencing overdiagnosis include the study population, screening protocol, and background incidence, limiting generalizability between settings. Reported rates of overtreatment vary widely in the literature, although contemporary international studies suggest increasing use of conservative management. Conclusions Epidemiological, clinical, and autopsy studies have been used to examine PCa overdiagnosis, with estimates ranging widely from 1.7% to 67%. Correspondingly, estimates of overtreatment vary widely based on patient features and may be declining internationally. Careful patient selection for screening and reducing overtreatment are important to preserve the benefits and reduce the downstream harms of prostate-specific antigen testing. Because all of these estimates are extremely population and context specific, this must be considered when using these data to inform policy. Patient summary Screening reduces spread and death from prostate cancer (PCa) but overdiagnoses some low-risk tumors that may not have caused harm. Because treatment has potential side effects, it is critical that not all patients with PCa receive aggressive treatment.

Original languageEnglish (US)
Pages (from-to)1046-1055
Number of pages10
JournalEuropean Urology
Volume65
Issue number6
DOIs
StatePublished - Jan 1 2014
Externally publishedYes

Fingerprint

Prostatic Neoplasms
Medical Overuse
Autopsy
Incidence
Prostate-Specific Antigen
Prostatectomy
Early Detection of Cancer
PubMed
Patient Selection
Population
Epidemiologic Studies
Neoplasms

Keywords

  • Overdiagnosis
  • Overtreatment
  • Prostate cancer
  • Prostate-specific antigen
  • Screening

ASJC Scopus subject areas

  • Urology

Cite this

Loeb, S., Bjurlin, M. A., Nicholson, J., Tammela, T. L., Penson, D. F., Carter, H. B., ... Etzioni, R. (2014). Overdiagnosis and overtreatment of prostate cancer. European Urology, 65(6), 1046-1055. https://doi.org/10.1016/j.eururo.2013.12.062

Overdiagnosis and overtreatment of prostate cancer. / Loeb, Stacy; Bjurlin, Marc A.; Nicholson, Joseph; Tammela, Teuvo L.; Penson, David F.; Carter, H. Ballentine; Carroll, Peter; Etzioni, Ruth.

In: European Urology, Vol. 65, No. 6, 01.01.2014, p. 1046-1055.

Research output: Contribution to journalReview article

Loeb, S, Bjurlin, MA, Nicholson, J, Tammela, TL, Penson, DF, Carter, HB, Carroll, P & Etzioni, R 2014, 'Overdiagnosis and overtreatment of prostate cancer', European Urology, vol. 65, no. 6, pp. 1046-1055. https://doi.org/10.1016/j.eururo.2013.12.062
Loeb S, Bjurlin MA, Nicholson J, Tammela TL, Penson DF, Carter HB et al. Overdiagnosis and overtreatment of prostate cancer. European Urology. 2014 Jan 1;65(6):1046-1055. https://doi.org/10.1016/j.eururo.2013.12.062
Loeb, Stacy ; Bjurlin, Marc A. ; Nicholson, Joseph ; Tammela, Teuvo L. ; Penson, David F. ; Carter, H. Ballentine ; Carroll, Peter ; Etzioni, Ruth. / Overdiagnosis and overtreatment of prostate cancer. In: European Urology. 2014 ; Vol. 65, No. 6. pp. 1046-1055.
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abstract = "Context Although prostate cancer (PCa) screening reduces the incidence of advanced disease and mortality, trade-offs include overdiagnosis and resultant overtreatment. Objective To review primary data on PCa overdiagnosis and overtreatment. Evidence acquisition Electronic searches were conducted in Cochrane Central Register of Controlled Trials, PubMed, and Embase from inception to July 2013 for original articles on PCa overdiagnosis and overtreatment. Supplemental articles were identified through hand searches. Evidence synthesis The lead-time and excess-incidence approaches are the main ways used to estimate overdiagnosis in epidemiological studies, with estimates varying widely. The estimated number of PCa cases needed to be diagnosed to save a life has ranged from 48 down to 5 with increasing follow-up. In clinical studies, generally lower rates of overdiagnosis have been reported based on the frequency of low-grade minimal tumors at radical prostatectomy (1.7-46.8{\%}). Autopsy studies have reported PCa in 18.5-38.5{\%}, although not all are low grade or low volume. Factors influencing overdiagnosis include the study population, screening protocol, and background incidence, limiting generalizability between settings. Reported rates of overtreatment vary widely in the literature, although contemporary international studies suggest increasing use of conservative management. Conclusions Epidemiological, clinical, and autopsy studies have been used to examine PCa overdiagnosis, with estimates ranging widely from 1.7{\%} to 67{\%}. Correspondingly, estimates of overtreatment vary widely based on patient features and may be declining internationally. Careful patient selection for screening and reducing overtreatment are important to preserve the benefits and reduce the downstream harms of prostate-specific antigen testing. Because all of these estimates are extremely population and context specific, this must be considered when using these data to inform policy. Patient summary Screening reduces spread and death from prostate cancer (PCa) but overdiagnoses some low-risk tumors that may not have caused harm. Because treatment has potential side effects, it is critical that not all patients with PCa receive aggressive treatment.",
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N2 - Context Although prostate cancer (PCa) screening reduces the incidence of advanced disease and mortality, trade-offs include overdiagnosis and resultant overtreatment. Objective To review primary data on PCa overdiagnosis and overtreatment. Evidence acquisition Electronic searches were conducted in Cochrane Central Register of Controlled Trials, PubMed, and Embase from inception to July 2013 for original articles on PCa overdiagnosis and overtreatment. Supplemental articles were identified through hand searches. Evidence synthesis The lead-time and excess-incidence approaches are the main ways used to estimate overdiagnosis in epidemiological studies, with estimates varying widely. The estimated number of PCa cases needed to be diagnosed to save a life has ranged from 48 down to 5 with increasing follow-up. In clinical studies, generally lower rates of overdiagnosis have been reported based on the frequency of low-grade minimal tumors at radical prostatectomy (1.7-46.8%). Autopsy studies have reported PCa in 18.5-38.5%, although not all are low grade or low volume. Factors influencing overdiagnosis include the study population, screening protocol, and background incidence, limiting generalizability between settings. Reported rates of overtreatment vary widely in the literature, although contemporary international studies suggest increasing use of conservative management. Conclusions Epidemiological, clinical, and autopsy studies have been used to examine PCa overdiagnosis, with estimates ranging widely from 1.7% to 67%. Correspondingly, estimates of overtreatment vary widely based on patient features and may be declining internationally. Careful patient selection for screening and reducing overtreatment are important to preserve the benefits and reduce the downstream harms of prostate-specific antigen testing. Because all of these estimates are extremely population and context specific, this must be considered when using these data to inform policy. Patient summary Screening reduces spread and death from prostate cancer (PCa) but overdiagnoses some low-risk tumors that may not have caused harm. Because treatment has potential side effects, it is critical that not all patients with PCa receive aggressive treatment.

AB - Context Although prostate cancer (PCa) screening reduces the incidence of advanced disease and mortality, trade-offs include overdiagnosis and resultant overtreatment. Objective To review primary data on PCa overdiagnosis and overtreatment. Evidence acquisition Electronic searches were conducted in Cochrane Central Register of Controlled Trials, PubMed, and Embase from inception to July 2013 for original articles on PCa overdiagnosis and overtreatment. Supplemental articles were identified through hand searches. Evidence synthesis The lead-time and excess-incidence approaches are the main ways used to estimate overdiagnosis in epidemiological studies, with estimates varying widely. The estimated number of PCa cases needed to be diagnosed to save a life has ranged from 48 down to 5 with increasing follow-up. In clinical studies, generally lower rates of overdiagnosis have been reported based on the frequency of low-grade minimal tumors at radical prostatectomy (1.7-46.8%). Autopsy studies have reported PCa in 18.5-38.5%, although not all are low grade or low volume. Factors influencing overdiagnosis include the study population, screening protocol, and background incidence, limiting generalizability between settings. Reported rates of overtreatment vary widely in the literature, although contemporary international studies suggest increasing use of conservative management. Conclusions Epidemiological, clinical, and autopsy studies have been used to examine PCa overdiagnosis, with estimates ranging widely from 1.7% to 67%. Correspondingly, estimates of overtreatment vary widely based on patient features and may be declining internationally. Careful patient selection for screening and reducing overtreatment are important to preserve the benefits and reduce the downstream harms of prostate-specific antigen testing. Because all of these estimates are extremely population and context specific, this must be considered when using these data to inform policy. Patient summary Screening reduces spread and death from prostate cancer (PCa) but overdiagnoses some low-risk tumors that may not have caused harm. Because treatment has potential side effects, it is critical that not all patients with PCa receive aggressive treatment.

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