***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: Prostate cancer ( PC ) mortality is the most valid end-point in screening trials , but could be influenced by the choice of initial treatment if treatment has an effect on mortality . In this study , PC treatment was compared between the screening and control arms in a screening trial . Data were collected from the European R and omized Study of Screening for Prostate Cancer ( ERSPC ) . The characteristics and initial treatment of PC cases detected in the screening and the control arm were compared . Polytomous logistic regression analysis was used to assess the influence of study arm on treatment , adjusting for potential confounders and with statistical imputation of missing values . A total of 8,389 PC cases were detected , 5,422 in the screening arm and 3,145 in the control arm . Polytomous regression showed that trial arm was associated with treatment choice after correction for missing values , especially in men with high-risk PC . A control subject with high-risk PC was more likely than a screen subject to receive  radiotherapy  ( OR : 1.43 , 95 % CI : 1.01 - 2.05 , p = 0.047 ) ,  expectant management  ( OR : 2.92 , 95 % CI : 1.33 - 6.42 , p = 0.007 ) or  hormonal treatment  ( OR : 1.77 , 95 % CI : 1.07 - 2.94 , p = 0.026 ) instead of  radical prostatectomy . However , trial arm had only a minor role in treatment choice compared to other variables . In conclusion , a small effect of trial arm on treatment choice was seen , particularly in men with high-risk PC . Therefore , differences in treatment between arms are unlikely to play a major role in the interpretation of the results of the ERSPC Background : Prostate cancer screening with prostate-specific antigen ( PSA ) has shown to reduce prostate cancer mortality in the European R and omised study of Screening for Prostate Cancer ( ERSPC ) trial . Overdetection and overtreatment are substantial unfavourable side effects with consequent healthcare costs . In this study the effects of introducing widespread PSA screening is evaluated . Methods : The MISCAN model was used to simulate prostate cancer growth and detection in a simulated cohort of 100 000 men ( European st and ard population ) over 25 years .  PSA screening from age 55 to 70 or 75 , with 1 , 2 and 4-year-intervals is simulated . Number of diagnoses , PSA tests , biopsies , treatments , deaths and corresponding costs for 100 000 men and for United Kingdom and United States are compared . Results : Without screening 2378 men per 100 000 were predicted to be diagnosed with prostate cancer compared with 4956 men after screening at 4-year intervals . By introducing screening , the costs would increase with 100 % to [ euro ] 60 695 000 . Overdetection is related to 39 % of total costs ( [ euro ] 23 669 000 ) . Screening until age 75 is relatively most expensive because of the costs of overtreatment . Conclusion : Introduction of PSA screening will increase total healthcare costs for prostate cancer substantially , of which the actual screening costs will be a small part BACKGROUND Several trials evaluating the effect of prostate-specific antigen ( PSA ) testing on prostate-cancer mortality have shown conflicting results . We up date d prostate-cancer mortality in the European R and omized Study of Screening for Prostate Cancer with 2 additional years of follow-up . METHODS The study involved 182,160 men between the ages of 50 and 74 years at entry , with a predefined core age group of 162,388 men 55 to 69 years of age . The trial was conducted in eight European countries . Men who were r and omly assigned to the screening group were offered PSA-based screening , whereas those in the control group were not offered such screening . The primary outcome was mortality from prostate cancer . RESULTS After a median follow-up of 11 years in the core age group , the relative reduction in the risk of death from prostate cancer in the screening group was 21 % ( rate ratio , 0.79 ; 95 % confidence interval [ CI ] , 0.68 to 0.91 ; P=0.001 ) , and 29 % after adjustment for noncompliance . The absolute reduction in mortality in the screening group was 0.10 deaths per 1000 person-years or 1.07 deaths per 1000 men who underwent r and omization . The rate ratio for death from prostate cancer during follow-up years 10 and 11 was 0.62 ( 95 % CI , 0.45 to 0.85 ; P=0.003 ) . To prevent one death from prostate cancer at 11 years of follow-up , 1055 men would need to be invited for screening and 37 cancers would need to be detected . There was no significant between-group difference in all-cause mortality . CONCLUSIONS Analyses after 2 additional years of follow-up consoli date d our previous finding that PSA-based screening significantly reduced mortality from prostate cancer but did not affect all-cause mortality . ( Current Controlled Trials number , IS RCT N49127736 . ) BACKGROUND The optimal upper limit of the normal range for prostate-specific antigen ( PSA ) is unknown . We investigated the prevalence of prostate cancer among men in the Prostate Cancer Prevention Trial who had a PSA level of 4.0 ng per milliliter or less . METHODS Of 18,882 men enrolled in the prevention trial , 9459 were r and omly assigned to receive placebo and had an annual measurement of PSA and a digital rectal examination . Among these 9459 men , 2950 men never had a PSA level of more than 4.0 ng per milliliter or an abnormal digital rectal examination , had a final PSA determination , and underwent a prostate biopsy after being in the study for seven years . RESULTS Among the 2950 men ( age range , 62 to 91 years ) , prostate cancer was diagnosed in 449 ( 15.2 percent ) ; 67 of these 449 cancers ( 14.9 percent ) had a Gleason score of 7 or higher . The prevalence of prostate cancer was 6.6 percent among men with a PSA level of up to 0.5 ng per milliliter , 10.1 percent among those with values of 0.6 to 1.0 ng per milliliter , 17.0 percent among those with values of 1.1 to 2.0 ng per milliliter , 23.9 percent among those with values of 2.1 to 3.0 ng per milliliter , and 26.9 percent among those with values of 3.1 to 4.0 ng per milliliter . The prevalence of high- grade cancers increased from 12.5 percent of cancers associated with a PSA level of 0.5 ng per milliliter or less to 25.0 percent of cancers associated with a PSA level of 3.1 to 4.0 ng per milliliter . CONCLUSIONS Biopsy-detected prostate cancer , including high- grade cancers , is not rare among men with PSA levels of 4.0 ng per milliliter or less -- levels generally thought to be in the normal range BACKGROUND The effectiveness of surgery versus observation for men with localized prostate cancer detected by means of prostate-specific antigen ( PSA ) testing is not known . METHODS From November 1994 through January 2002 , we r and omly assigned 731 men with localized prostate cancer ( mean age , 67 years ; median PSA value , 7.8 ng per milliliter ) to radical prostatectomy or observation  and followed them through January 2010 . The primary outcome was all-cause mortality ; the secondary outcome was prostate-cancer mortality . RESULTS During the median follow-up of 10.0 years , 171 of 364 men ( 47.0 % ) assigned to radical prostatectomy  died , as compared with 183 of 367 ( 49.9 % ) assigned to observation ( hazard ratio , 0.88 ; 95 % confidence interval [ CI ] , 0.71 to 1.08 ; P=0.22 ; absolute risk reduction , 2.9 percentage points ) . Among men assigned to radical prostatectomy , 21 ( 5.8 % ) died from prostate cancer or treatment , as compared with 31 men ( 8.4 % ) assigned to observation ( hazard ratio , 0.63 ; 95 % CI , 0.36 to 1.09 ; P=0.09 ; absolute risk reduction , 2.6 percentage points ) . The effect of treatment on all-cause and prostate-cancer mortality did not differ according to age , race , coexisting conditions , self-reported performance status , or histologic features of the tumor . Radical prostatectomy was associated with reduced all-cause mortality among men with a PSA value greater than 10 ng per milliliter ( P=0.04 for interaction ) and possibly among those with intermediate-risk or high-risk tumors ( P=0.07 for interaction ) . Adverse events within 30 days after surgery occurred in 21.4 % of men , including one death . CONCLUSIONS Among men with localized prostate cancer detected during the early era of PSA testing  , radical prostatectomy did not significantly reduce all-cause or prostate-cancer mortality , as compared with observation , through at least 12 years of follow-up . Absolute differences were less than 3 percentage points . ( Funded by the Department of Veterans Affairs Cooperative Studies Program and others ; PIVOT Clinical Trials.gov number , NCT00007644 . ) PURPOSE Robotic-assisted laparoscopic radical prostatectomy is eclipsing open radical prostatectomy among men with clinical ly localized prostate cancer . The objective of this study was to compare the risks of problems with continence and sexual function following these procedures among Medicare-age men . PATIENTS AND METHODS A population -based r and om sample was drawn from the 20 % Medicare cl aims files for August 1 , 2008 , through December 31 , 2008 . Participants had hospital and physician cl aims for radical prostatectomy and diagnostic codes for prostate cancer and reported undergoing either a robotic or open surgery .  They received a mail survey that included self-ratings of problems with continence and sexual function a median of 14 months postoperatively . RESULTS Completed surveys were obtained from 685 ( 86 % ) of 797 eligible participants , and 406 and 220 patients reported having had  robotic or open surgery , respectively . Overall , 189 ( 31.1 % ; 95 % CI , 27.5 % to 34.8 % ) of 607 men reported having a moderate or big problem with continence , and 522 ( 88.0 % ; 95 % CI , 85.4 % to 90.6 % ) of 593 men reported having a moderate or big problem with sexual function . In logistic regression models predicting the log odds of a moderate or big problem with postoperative continence and adjusting for age and educational level , robotic prostatectomy was associated with a nonsignificant trend toward greater problems with continence ( odds ratio [ OR ] 1.41 ; 95 % CI , 0.97 to 2.05 ) . Robotic prostatectomy was not associated with greater problems with sexual function ( OR , 0.87 ; 95 % CI , 0.51 to 1.49 ) . CONCLUSION Risks of problems with continence and sexual function are high after both procedures . Medicare-age men should not expect fewer adverse effects following robotic prostatectomy BACKGROUND Prostate cancer is one of the leading causes of death from malignant disease among men in the developed world . One strategy to decrease the risk of death from this disease is screening with prostate-specific antigen ( PSA ) ; however , the extent of benefit and harm with such screening is under continuous debate . METHODS In December , 1994 , 20,000 men born between 1930 and 1944 , r and omly sample d from the population register , were r and omised by computer in a 1:1 ratio to either a screening group invited for PSA testing every 2 years ( n=10,000 ) or to a control group not invited ( n=10,000 ) . Men in the screening group were invited up to the upper age limit ( median 69 , range 67 - 71 years ) and only men with raised PSA concentrations were offered additional tests such as digital rectal examination and prostate biopsies . The primary endpoint was prostate-cancer specific mortality , analysed according to the intention-to-screen principle . The study is ongoing , with men who have not reached the upper age limit invited for PSA testing . This is the first planned report on cumulative prostate-cancer incidence and mortality calculated up to Dec 31 , 2008 . This study is registered as an International St and ard R and omised Controlled Trial IS RCT N54449243 . FINDINGS In each group , 48 men were excluded from the analysis because of death or emigration before the r and omisation date , or prevalent prostate cancer . In men r and omised to screening , 7578 ( 76 % ) of 9952 attended at least once . During a median follow-up of 14 years , 1138 men in the screening group and 718 in the control group  were diagnosed with prostate cancer , result ing in a cumulative prostate-cancer incidence of 12.7 % in the screening group and 8.2 
    Output:
    
Harms associated with screening include false-positive results and complications of biopsy and treatment .
AND RELEVANCE Available evidence favors clinician discussion of the pros and cons of PSA screening with average-risk men aged 55 to 69 years .