Impact of Prostatic-specific Antigen Threshold and Screening Interval in Prostate Cancer Screening Outcomes: Comparing the Swedish and Finnish European Randomised Study of Screening for Prostate Cancer Centres

Background: The European Randomised Study of Screening for Prostate Cancer trial has shown a 21% reduction in prostate cancer (PC) mortality with prostate-specific antigen (PSA)-based screening. Sweden used a 2-yr screening interval and showed a larger mortality reduction than Finland with a 4-yr interval and higher PSA cut-off. Objective: To evaluate the impact of screening interval and PSA cut-off on PC detection and mortality. Design, setting, and participants: We analysed the core age groups (55-69 yr at entry) of the Finnish (N = 31 866) and Swedish (N = 5901) screening arms at 13 yr and 16 yr of follow-up. Sweden used a screening interval of 2 yr and a PSA cut-off of 3.0 ng/ml, while in Finland the screening interval was 4 yr and the PSA cut-off 4.0 ng/ml (or PSA 3.0-3.9 ng/ml with free PSA < 16%). Outcome measurements and statistical analysis: We compared PC detection rate and PC mortality between the Finnish and Swedish centres and estimated the impact of different screening protocols. Results and limitations: If the Swedish screening protocol had been followed in Finland, 122 additional PC cases would have been diagnosed at screening, 84% of which would have been low-risk cancers, and four leading to PC death. In contrast, if a lower PSA threshold had been applied in Finland, at least 127 additional PC would have been found, with 19 PC deaths. Conclusions: The small number of deaths among cases that would have been potentially detectable in Finland with the Swedish protocol (or those that would have been missed in Sweden with the Finnish approach) is unlikely to explain the differences in mortality in this long of a follow-up. Patient summary: A prostate-specific antigen threshold of 3 ng/ml versus 4 ng/ml or a screening interval of 2 yr instead of 4 yr is unlikely to explain the larger mortality reduction achieved in Sweden compared with Finland. (c) 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.