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Prostate Cancer Screening with Prostate-Specific Antigen Testing: More Answers or More Confusion?

Prostate cancer is a leading cause of morbidity and mortality among middle-aged and older men. Of the solid tumors prostate cancer is rather unique in that it presents in 2 distinct forms, a latent form, which grows slowly and poses no threat to the patient’s life, and an aggressive form, which metastasizes quickly and kills the patient. The discovery of prostate-specific antigen (PSA)² and the demonstration of its utility for early diagnosis and monitoring of prostatic carcinoma have raised hopes that this simple serological test could be invaluable in screening asymptomatic individuals for early prostate cancer diagnosis. The premise is that such early diagnosis may then lead to early therapeutic interventions, which should improve the overall survival of prostate cancer patients. However, PSA screening of asymptomatic individuals has remained controversial during the last 15 years owing to the lack of evidence for improved patient survival. Recently, the results of 2 major randomized clinical trials on the effectiveness of PSA as a screening tool, from both the US and Europe, have been published. These results are not clear cut. For this reason, the controversy surrounding prostate cancer screening will likely continue for years. Below, we examine this issue with 4 authorities in the field.

What do you think is driving the widespread use of PSA testing for prostate cancer screening over the last decade, despite the absence of evidence for its benefit?

Patrick Walsh³ : Undisputed evidence for benefit! There is no debate that PSA testing has made it possible to diagnose prostate cancer at an earlier, curable stage. Because prostate cancer produces no symptoms until it is far advanced, before PSA testing most patients presented with incurable disease—either locally advanced or metastatic. However, following the advent of PSA testing, suddenly it became possible to diagnose prostate cancer at an earlier curable stage. According to data from the American Cancer Society, in 1990 only 68% of men presented with localized disease and 20.6% had metastatic disease. In 2009, 91% . . . [Full Text of this Article]

Question # 2: Mortality from prostate cancer in the US has fallen by about 4% per year since 1992. Is it because of the voluntary PSA screening or some other reasons?

Question # 3: Why do you think that the 2 large, randomized trials on prostate cancer screening reached seemingly contradictory results? (New Engl J Med 2009;360:1310–9 and 1320–8.)

Question # 4: Do you think the data released by the 2 aforementioned studies were premature? And should we expect more updates? And when? Could these updates substantially change the picture we have now?

Question # 5: Based on the released data, would you recommend PSA screening to your patients? How would you justify your recommendation (yes or no) to them?

Question # 6: Did you ever measure your own PSA and why or why not?

Question # 7: Can you identify a possible scenario (e.g., with a better marker or imaging) by which the side effects of screening (overdiagnosis and overtreatment) would be eliminated or diminished?

Question # 8: Do you have any other general or specific comments on this topic?