Open Access Open Badges Research article

Empirical estimates of prostate cancer overdiagnosis by age and prostate-specific antigen

Andrew J Vickers2*, Daniel D Sjoberg2, David Ulmert16, Emily Vertosick2, Monique J Roobol4, Ian Thompson78, Eveline AM Heijnsdijk5, Harry De Koning5, Coral Atoria-Swartz2, Peter T Scardino1 and Hans Lilja136

Author Affiliations

1 Department of Surgery (Urology), Memorial Sloan-Kettering Cancer Center, New York, NY, USA

2 Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY, USA

3 Laboratory Medicine and Medicine (GU-Oncology), Memorial Sloan-Kettering Cancer Center, New York, NY, USA

4 Department of Urology, Erasmus University Medical Center, Rotterdam, Netherlands

5 Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands

6 Departments of Laboratory Medicine and Clinical Sciences in Malmö, Lund University, University Hospital UMAS, Malmö, Sweden

7 The Cancer Therapy and Research Center, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA

8 Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK

For all author emails, please log on.

BMC Medicine 2014, 12:26  doi:10.1186/1741-7015-12-26

Published: 11 February 2014



Prostate cancer screening depends on a careful balance of benefits, in terms of reduced prostate cancer mortality, and harms, in terms of overdiagnosis and overtreatment. We aimed to estimate the effect on overdiagnosis of restricting prostate specific antigen (PSA) testing by age and baseline PSA.


Estimates of the effects of age on overdiagnosis were based on population based incidence data from the US Surveillance, Epidemiology and End Results database. To investigate the relationship between PSA and overdiagnosis, we used two separate cohorts subject to PSA testing in clinical trials (n = 1,577 and n = 1,197) and a population-based cohort of Swedish men not subject to PSA-screening followed for 25 years (n = 1,162).


If PSA testing had been restricted to younger men, the number of excess cases associated with the introduction of PSA in the US would have been reduced by 85%, 68% and 42% for age cut-offs of 60, 65 and 70, respectively. The risk that a man with screen-detected cancer at age 60 would not subsequently lead to prostate cancer morbidity or mortality decreased exponentially as PSA approached conventional biopsy thresholds. For PSAs below 1 ng/ml, the risk of a positive biopsy is 65 (95% CI 18.2, 72.9) times greater than subsequent prostate cancer mortality.


Prostate cancer overdiagnosis has a strong relationship to age and PSA level. Restricting screening in men over 60 to those with PSA above median (>1 ng/ml) and screening men over 70 only in selected circumstances would importantly reduce overdiagnosis and change the ratio of benefits to harms of PSA-screening.

Prostate cancer; Early detection; Overdiagnosis; PSA; Screening