Prostate cancer incidence and mortality in Europe: implications for screening activities

Prostate cancer in Europe: the statistics

Prostate cancer is the most commonly diagnosed cancer in men and the third leading cause of cancer-related deaths among males in Europe. In the European Economic Area, which includes the 26 member states of the European Union, Iceland, Liechtenstein, and Norway, with a population of 219 million men, approximately 341,000 were diagnosed with prostate cancer in 2020 (accounting for 23% of all male cancers). In the same year, around 71,000 men died from prostate cancer (representing 10% of all male cancer-related deaths). There is a significant gap between the number of new diagnoses and the number of deaths from this malignancy, which explains why about 4 million Europeans (equivalent to 1.7% of all men) are living after a prostate cancer diagnosis.

Prostate cancer screening with PSA: a controversial history

Screening is the systematic application of tests or examinations to identify individuals with a potential disease or condition within an asymptomatic population. The main goal of a population-based cancer screening program is to reduce mortality from a specific cancer or to decrease its incidence, meaning the number of new malignant cases (for example, by removing precancerous lesions, as in the case of cervical or colorectal cancers). However, while screening aims to detect diseases early and improve outcomes, it can also lead to overdiagnosis, i.e., the diagnosis of a cancer that, if left undetected, would not have caused any negative effects on the person’s health during their lifetime, nor symptoms, nor death (for example, because they grow slowly, or because the patient is affected by other diseases that will compromise their survival before the cancer itself). A screening program needs to balance benefits and harms, i.e., reduced mortality against harms, like overdiagnosis and unnecessary treatments.

In the case of prostate cancer, screening with the PSA test (prostate-specific antigen) aims to reduce mortality from prostate cancer, but it can lead to overdiagnosis and overtreatment. Studies have shown that up to one-third of men of screening age might have prostate cancer that will never produce symptoms. The two largest randomized studies on prostate cancer screening with PSA have shown conflicting results, and due to the delicate balance between risks and benefits demonstrated by these studies, almost all European countries, except for Lithuania, have chosen not to implement population-based screening programs for prostate cancer. Instead, they have preferred to promote shared decision-making between healthy adults (i.e., without symptoms attributable to prostate cancer) and their doctors regarding the frequency and age at which to conduct PSA tests.

Individual attitudes and local practices regarding the PSA test, in a context of opportunistic screening without clear protocols, may lead to a different balance between benefits and risks at the population level than what was observed in randomized clinical trials. In particular, there is concern that this approach may result in fewer benefits (in terms of lives saved) and more risks of overdiagnosis.

A recent IARC population-based study

Recently, we at the International Agency for Research on Cancer (IARC), in collaboration with researchers from institutions including the Centro di Riferimento Oncologico di Aviano and Sun Yat-sen University in Guangzhou, China, have analysed the epidemiological patterns of prostate cancer incidence and mortality across 26 European countries. We have assessed how incidence rates vary geographically and over time, also considering the frequency of PSA testing in each population. Variations in Incidence and Mortality

Between 1980 and 2017, prostate cancer incidence rates increased across Europe, but the magnitude of this rise varied significantly between countries (Figure 1). In contrast, mortality rates were much lower and exhibited far less variation compared to incidence rates. Most countries experienced a consistent decline in mortality, with smaller temporal differences among nations. During the study period, a twenty-fold difference in incidence rates was observed between the countries with the highest and lowest incidence, while the variation in mortality rates between countries was five-fold (Figure 1).

Temporal correlation between prostate cancer incidence and PSA testing use

It is particularly significant that, in each country, the variation in prostate cancer incidence rates closely followed the temporal changes in the frequency of PSA testing, as shown in Figure 2.

Figure 2. Temporal variation in prostate cancer incidence rates in relation to the temporal trends of PSA testing. Source: Vaccarella S et al. BMJ 2024 ; https://doi.org/10.1136/bmj-2023-077738

Interpretation of results

These findings, based on consistent population data, are consistent with a significant overdiagnosis of prostate cancer, driven by opportunistic screening with the PSA test, and suggest a possible minimal reduction in mortality.

Implications for the new EU recommendations

This study is particularly relevant given that the European Union, through the “Europe’s Beating Cancer Plan” has recently issued recommendations for a new prostate cancer screening strategy. Specifically, the EU suggests that countries proceed gradually, starting with pilot projects and conducting further research to understand whether it is possible to organize programs that effectively contain overdiagnosis. These programs propose PSA testing (a blood test) for men up to 70 years old, along with MRI scans as a follow-up test in cases of elevated PSA values. The use of MRI before biopsy and targeted prostate biopsies, as opposed to systematic biopsies, is expected to reduce the risk of overdiagnosis or unnecessary treatments for diseases that are indolent and do not require intervention.

Given the already high levels of overdiagnosis, and the uncertainty about how MRI usage can reduce it, the national healthcare system, supported by the medical-scientific community, will need to implement these recommendations carefully. This should include considering the impact on waiting lists and ensuring, as much as possible, that individuals do not seek these tests privately, which would exacerbate disparities between those who can afford healthcare costs and those who cannot.

Conclusions

The results of this new study suggest that spontaneous screening programs for prostate cancer offer limited benefits in terms of population-level mortality reduction but result in a high rate of overdiagnosis among men. The potential implementation of national or regional organized prostate cancer screening programs must be approached with great caution to minimize the harms of overdiagnosis, which is already widespread in Europe. Even if the use of MRI reduces overdiagnosis, it is still unclear to what extent this can be mitigated, making it essential to carefully evaluate the risks and benefits of such programs and continuously monitor them through population studies and cancer registries.

Vaccarella S, et al. Prostate cancer incidence and mortality in Europe: a baseline for proposed prostate cancer screening programmes in the European Union. BMJ, 4 September 2024 ; https://doi.org/10.1136/bmj-2023-077738

Written by Dr Salvatore Vaccarella, Scientist – Cancer Inequalities Team https://cancer-inequalities.iarc.who.int/ 

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