A Step Backward: The ACPM Recommendations on Prostate Cancer Screening

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http://www.medscape.com/viewarticle/571675?src=mp & spon=17 & uac=113983MZ

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PSA

testing provides a powerful marker for prostate cancer risk and aggressiveness,

including the risk of dying from prostate cancer. Generally, the higher the PSA

and the more rapidly it is increasing, the greater the risk of high-grade

disease and the prostate cancer-specific mortality.[4]

Indeed,

longitudinal studies with PSA measurements and PSA velocity from men in their

30s and 40s have linked this with the risk of subsequent prostate cancer

diagnosis and cancer-specific survival many years later.[5,15,16]

Moreover, prostate cancers treated at lower PSA levels have better outcomes

than those treated at higher PSA levels.[17]

Reports

of over-diagnosis are exaggerated, and prostate cancer continues to be

diagnosed more often too late than too early. Most PSA-detected cancers have

the histopathologic features of significant cancers. In addition, there are

numerous parameters that are useful in selectively identifying clinically

significant cancers, including the Gleason grade and extent of cancer in the biopsy

specimens, as well as PSA density and PSA velocity. If screening detected only

harmless cancers, treating them could not produce the striking decline in

prostate cancer mortality rates that have occurred.

There is

evidence from a randomized trial that convincingly demonstrates that treatment

of early stage disease is effective. Similar findings were reported using

Medicare data, wherein treatment of early prostate cancer reduced

prostatecancer-specific mortality. One of the widely publicized negative case-control

studies[18] does not have adequate follow-up, and the researchers

did not examine prostate cancer-specific mortality. Policy decisions regarding

screening should not be decided one way or the other on the basis of such

studies. In contrast, a recently reported case-control study[19]

showing a 62% reduction in prostate cancer-specific mortality in men younger

than the age of 65 has not received wide publicity or attention in deciding

policy.

Regardless

of the ACPM recommendations, the prostate cancer screening train has left the

station. Should we stop screening to prevent side effects? Should we go back to

a 20% rate of metastatic disease at diagnosis and a 35% higher mortality rate?

Or, rather, should we continue to strive to improve the accuracy of screening

and the quality of treatment?

The

senior author recommends that annual screening should be initiated at age 40

with informed patient management, to avoid under-diagnosis. Aggressive cancers

can be identified through the combined use of PSA-based parameters and biopsy

findings. Rather than eliminating screening and the possibility for early

diagnosis in healthy men, we should combat the risks of over-diagnosis through

careful patient selection and the provision of high-quality treatment. Clearly,

avoiding 27,000 prostate cancer deaths per year is worth the tradeoffs.