LETTER TO THE EDITOR

Misconceptions about Swedish organised prostate cancer testing

Ola Bratt

Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden

KEYWORDS: Bladder cancer; Complications; Quality of life

 

 

Dear Editor,

We appreciate Dr Takahashi’s interest in our article about the Swedish, regional, population-based model for organised prostate cancer testing (OPT) [1]. Although we share many of his views about the uncertainty of the benefit and harms of screening for prostate cancer, we would like to correct some misconceptions.

• Swedish OPT is not research, so the Declaration of Helsinki’s requirements for informed consent do not apply. For the same reason, Dr Takahashi’s concern about the lack of a control group for evaluating the OPT programmes’ effect on overall survival is irrelevant. Swedish OPT is a way for the public healthcare providers to reduce the harm of the widespread unorganised prostate cancer-specific antigen (PSA) testing. As the men receive neutral information about the potential benefits and harms, a choice to participate can be viewed as a similar non-written informed consent as given by patients to other healthcare interventions in Sweden (in contrast to in many other countries, written consent is not required for medical interventions in Sweden).
• The aim to improve cost-effectiveness has the ongoing unorganised testing in Sweden as the comparator, not a hypothetic setting with no or minimal PSA testing of men without symptoms or signs of prostate cancer. Evidence suggests that OPT has the potential to improve cost-effectiveness of prostate cancer testing in Sweden [2]; we do not claim that OPT would do so in other countries with lower prostate cancer mortality, less widespread unorganised PSA testing or a different healthcare system.
• Although the Swedish healthcare authorities in 2018 recommended against a national screening programme for prostate cancer, they do not oppose the regional OPT programmes. On the contrary, they support them: ‘The National Board of Health and Welfare welcomes these initiatives, which may lead to increased knowledge and more equal and effective diagnosis of prostate cancer’ [3].
• There is not, as Dr Takahashi claims, level 1 evidence that a long-term screening programme for prostate cancer does not prolong overall survival. The absence of evidence is not evidence of absence. The reported randomised screening trials were designed to detect an effect on prostate cancer-specific mortality in the invited population, not any effect on overall mortality. To do so, they would have to include manyfold more men. Furthermore, the magnitude of the effect for participating men is not the same as the magnitude of the effect in the invited population.

We hope that our response brings clarity to these important aspects of the Swedish model for OPT.

Sincerely yours

Ola Bratt, on behalf of all the authors of the article about OPT [1]

Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden. Email ola.bratt@gu.se

References

1. [1]     Bratt O, Butt ST, Carlsson C, et al. Swedish regional population-based organised prostate cancer testing: why, what and how? Scand J Urol. 2026;60;97–104. https://doi.org/10.2340/sju.v60.43809
2. [2]     Arnsrud Godtman R, Holmberg E, Lilja H, et al. Opportunistic testing versus organized prostate-specific antigen screening: outcome after 18 years in the Göteborg randomized population-based prostate cancer screening trial. Eur Urol. 2015;68:354–60. https://doi.org/10.1016/j.eururo.2014.12.006
3. [3]     Socialstyrelsen. Screening för prostatacancer. Rekommendation och bedömningsunderlag: Socialstyrelsen [Internet]. [In Swedish]. 2018 [cited 2025 June 11]. Available from: https://www.socialstyrelsen.se/regler-och-riktlinjer/nationella-screeningprogram/slutliga-rekommendationer/prostatacancer/