What is the Swedish OPT concept? The Swedish healthcare authorities do not recommend population-based screening for prostate cancer. However, in 2018 they commissioned the Confederation of Regional Cancer Centres to standardise the widespread unorganised PSA testing. An expert group recommended the OPT concept, as described in detail online. In essence, the Swedish OPT programmes are a form of population-based screening, but the regional organisation and their purposes make them different from a national screening programme. Whereas the purpose of a national screening programme is to reduce morbidity and mortality of the target condition, OPT has the following three main purposes:
- To improve the effectiveness of the ongoing PSA testing: OPT is more effective and cost-effective than unorganised PSA testing. OPT invitations and test result notifications are managed by specific OPT offices and a national administrative IT system. The diagnostic algorithm for OPT relies on risk-stratified PSA testing intervals, pre-biopsy MRI, and standardised criteria for targeted and systematic biopsies.
- To improve equality: Information about the pros and cons of OPT and invitations to participate are offered to all men in selected age groups. In contrast, knowledge about the option of unorganised PSA testing is unequally spread across socioeconomic groups. Moreover, many men who opt for unorganised PSA testing are unaware of the potential negative consequences.
- To gain knowledge: Unorganised PSA testing contributes little to the evidence-base for prostate cancer screening, whereas all results of the Swedish OPT programmes are prospectively registered in the national SweOPT register. OPT will contribute with important knowledge about organisational and diagnostic aspects of prostate cancer screening. The present article is an example of this.
What does the present study tell us? The most important message is that the OPT programmes and their diagnostic pathway work well, although some parts may not be applicable in other countries. The participation-rate may seem low (35% of 68,060 invited men) but one must keep in mind that only 50-year-old men were invited. Participation rates will rise with age. Another important message is that the diagnostic algorithm with a pre-biopsy MRI avoided biopsy in 68% of men with PSA ≥ 3 ng/ml. This means that the harms of OPT are much reduced in comparison with a systematic biopsy for all men with PSA ≥ 3 ng/ml, which was used in the European Randomised Study of Screening for Prostate Cancer (ERSPC). A third important finding is the inter-regional differences in diagnostic outcomes. The proportion of men with PSA ≥ 3 ng/ml, and – as a consequence – also the proportion of men who had an MRI scan, ranged from 2.3% to 4.0% across the three regions. The reason is mainly related to the use of different PSA assays. There were also substantial differences in MRI scoring. The study highlights the need for registration and feedback of diagnostic results and standardisation of tests and investigations throughout the diagnostic pathway in prostate cancer screening programmes.
Written by: Ola Bratt, MD, PhD, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg; Department of Urology, Sahlgrenska University Hospital, Gothenburg, Sweden
Read the Abstract