Public health perspective on prostate-specific antigen screening: Implications of overdiagnosis and differences in health insurance systems across countries

Jackson et al. ¹ summarize guidelines for prostate-specific antigen (PSA) screening that vary by country and point to the need for appropriate decision aids. It has been carefully reviewed, and the differences and problems of each country's guidelines are clearly described. For any new decision aid, I would like to recommend that three points be taken into consideration:

Urologists and public health physicians have slightly different ideas.

Since prostate cancer is a cancer of the elderly, the risk of death from other causes is overwhelmingly higher than that from cancer. Improvements in cancer-specific mortality have no benefit unless overall survival (OS) changes. If only the cause of death changes and the length of life remains the same, there is no need for early detection and treatment.^4,5 In the UK, attempts to encourage PSA screening of high-risk populations, such as men of Black race, have been criticized.^6,7 The prostate cancer mortality rate of 5.4 per 10,000 may become 10.8 in the high-risk group, but we don't know how the screening group mortality rate would change, from 4.3 per 10,000 (according to USPSTF summary ⁵ ), and there would be no change in the OS. Higher risk does not necessarily mean greater benefit from screening. In addition, it is known that the mortality rate of prostate cancer is extremely low in Asians. Screening is less and less relevant, and the benefit, if any, will be even smaller. Urologists do not adequately understand the recommendations of public health physicians. ⁸ One of the reasons why there is no PSA screening program in the UK is that the National Health Service, made up of many public health physicians, respects the fact that there is insufficient evidence of its efficacy and cost-effectiveness.

The USPSTF does not recommend publically funded screening. Grade C recommendations are for private insurance coverage. In other words, in the US, you should be well informed, be convinced, pay, and take responsibility for the consequences yourself. The UK and Canada have public medical insurance and no PSA screening. In Japan, a group of public health physicians published a guideline in 2009 ⁹ that is nearly identical to the 2018 USPSTF statement. Urologists were initially members of the group and involved in the development of the guideline, but they resigned because they were unhappy with the content and have since developed their own, ¹⁰ recommending PSA screening for all age groups and almost identical to the 2012 AUA comments. Even after the AUA approved the USPSTF statement in 2018, it has yet to be revised. The prostate cancer mortality among Japanese, the Asian ethnic, is known to be extremely low compared to Caucasians, and the benefit of PSA screening, if any, should be negligible. In addition, 70% of all medical expenses are covered by public insurance. Furthermore, Japan's population is aging, with those aged 70 and over making up a large portion of the population. Urologists have more influence than public health physicians, which has led to the unusual situation where tens of thousands of prostatectomies are performed annually in Japan. Other Asian and European countries have similar problems. In fact, PSA screening should not be recommended in these countries.