EAU 2009: European Data Provide Proof of Prostate Cancer Screening Benefit, Say Experts

Fran Lowry

March 19, 2009

March 19, 2009 — The new data from the European study that showed a reduction in mortality from prostate cancer in men who were screened for the disease provide proof of the benefits of screening, said the lead investigator.

Clinicians can now tell their patients there is proof that screening for prostate cancer will decrease their probability of dying from the disease, Fritz Schröder, MD, from the Erasmus Medical Center, in Rotterdam, the Netherlands, told Medscape Oncology. Before this study, clinicians would have to admit to their patients that they did not know whether prostate cancer screening reduced the rate of death from prostate cancer, he said in an interview here at the European Association of Urology (EAU) 24th Annual Congress, where he presented the data.

The study, known as the European Randomized Trial of Screening for Prostate Cancer (ERSPC), found that prostate-specific antigen (PSA) screening was associated with a 20% reduction in the rate of death from prostate cancer. It showed an absolute reduction of approximately 7 prostate-cancer-related deaths per 10,000 men screened.

The results were published online March 18 in the New England Journal of Medicine, and have already been reported by Medscape Oncology. However, published at the same time was a large study from the United States that found no reduction in mortality from prostate cancer screening. An accompanying editorial noted that prostate cancer screening remains a controversial issue because it is so difficult to weigh the benefits against potential harms, which include overtreatment.

It is well known that, for some patients, a diagnosis of prostate cancer can lead to unnecessary treatment, which can be associated with major adverse effects, Dr. Schröder explained. Some cases of prostate cancer are very slow growing and may not warrant treatment, but instead can be followed with active surveillance or "watchful waiting."

"For this reason, overtreatment resulting from overdiagnosis is unwarranted and represents a major clinical problem," he said. "Now, the patient can be told that if he considers screening, then he would have a chance of decreasing the probability of his dying of prostate cancer by about 25%. That is a major change in the present clinical situation."

Dr. Schröder agreed that the controversy over unnecessary treatment remains very much open. However, he pointed out that researchers are getting closer to developing a reliable way to distinguish indolent from aggressive cancers. "We would really like to have a test, like the PSA test, that allows us to selectively identify those aggressive cancers, but we don't just now. What we do have, however, are nomograms that use a number of different indicators and allow us to decrease the number of biopsies, specifically in the low PSA ranges, where most of these potentially harmless cancers are found."

According to Schröder, the use of a nomogram can identify almost one third of the cases of indolent cancers. "This is also listed in our paper. If you apply that prostate-risk indicator, you identify 30% of men who can be advised not to be treated but to be managed by active surveillance. This is what we recommend at this time to decrease that enormous amount of overdiagnosis. Such nomograms can be found on the European Association of Urology's Web site."

Screening Shows Benefit for First Time

Approached for an independent comment, Freddie C. Hamdy, MD, from the Oxford Radcliffe Hospital, in the United Kingdom, agreed that for the first time, screening asymptomatic 55- to 69-year-old men appears to show benefit. But, he insisted, that benefit comes at a price.

"To prevent some men from dying of prostate cancer, you are diagnosing many, many men and, by doing so, and this is something that many people do not realize — you are giving themthe label of a cancer patient. These are healthy men, they are leading good lives, they are happy, and suddenly they become a cancer patient. The effect of that is underestimated," he told Medscape Oncology in an interview during the EAU meeting.

A further analysis of the ERSPC study will delve into quality-of-life issues, and the results should be very interesting, Dr. Hamdy said.

Most men, when faced with a diagnosis of prostate cancer, want treatment, that is their gut reaction, Dr. Hamdy said. But, he pointed out, "only a small proportion of men with screen-detected prostate cancer are going to die from prostate cancer. It takes a lot of explanation to convince a patient that, yes, he has cancer, but that he doesn't need treatment, he needs to be followed up. Compounding that difficulty is the fact that we don't have reliable methods for following these men that will tell us they are safe or if they now need treatment."

Both Dr. Schröder and Dr. Hamdy agree that developing a reliable fail-safe method to let clinicians know just when to initiate treatment is key. "This is probably the most urgent area of research we need to focus on," said Dr. Hamdy.

Right now, physicians and their prostate cancer patients remain on the horns of a dilemma. And, said Dr. Hamdy, studies such as the ERSPC are not taking that dilemma away. "It is continuing. I don't think that governments are going to jump on the evidence and say, fantastic, we are now going to screen for prostate cancer. I don't think they will do that. I hope that they are not going to do that, because the cost of that, to society and to men, is going to be very considerable."

In the United Kingdom, the new results have led to a prostate cancer charity calling for nationwide screening, which at present is not offered as a standard (unlike mammograms for breast cancer screening). In the United Kingdom, men older than 45 years can ask their family doctor for a PSA test, but only an estimated 6% of men do so. Health minister Ann Keen said that she will ask the UK National Screening Committee to review the new evidence and make recommendations, says a news report on the National Health Service website.

Dr. Schr ö der and Dr. Hamdy have disclosed no relevant financial relationships.

N Engl J Med. Published online before print March 18, 2009.

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