What Did We Learn About Urology in 2011?

Edwin Darracott Vaughan, MD


November 23, 2011

In This Article

Game-Changing Research in Urology

Urology is such a diverse field that identifying the "top" advances in a given year is almost impossible. However, the following review describes some of the most significant milestones that will change the practice of urology and help shape future avenues for research.

Early Diagnosis of Prostate Cancer

The US Preventive Services Task Force (USPSTF) issued a surprising and unexpected preliminary report in October,[1] recommending against routine prostate-specific antigen (PSA) testing for the early detection of prostate cancer. This is clearly the biggest "game-changing" development in urology this past year.

The most articulate article countering this position reviewed the considerable evidence that early screening can reduce prostate cancer deaths.[2]The initial report of the European Randomized Study of Prostate Cancer Screening (ERSPC) reported a 20% lower prostate cancer death rate in the screening group.[3] A later, better-controlled trial from Göteborg, Sweden, showed an astounding 44% lower prostate cancer death rate in men who received screening.[4] The only true screening study, in which more than 90% of the men were screened, was conducted in Austria. In the Tyrol area of the country, men who had PSA testing were compared with men in other areas of Austria where PSA was not commonly measured. The reduction in prostate cancer death rate was 54% in the Tyrol group compared with 29% in the nonscreened areas of Austria.[5] Secondly, with a growing elderly population in the United States, we could have predicted that the prostate cancer death rate in this country would have risen over the past decades. Instead, prostate cancer deaths in the United States have fallen from more than 51,000 in 1992 to about 35,000 in 2007.[6] The finding of metastatic disease at the time of diagnosis has fallen a remarkable 75%.[6]

With all of this information, why did the USPSTF reach the conclusion that PSA testing was unnecessary? A unique aspect of prostate cancer, as opposed to other cancers, is that many men die with the disease, not of it. There are indolent forms of the disease that do not need treatment. The finding of an elevated PSA often leads to a biopsy, with attendant risks for complications, followed by unnecessary overtreatment, potentially resulting in more lasting complications, such as sexual dysfunction and urinary incontinence.

Reviewing the available literature, it is possible to calculate the number needed to treat to prevent a single death from prostate cancer. In the ERSPC, that number was 48. In other words, 47 men may have been treated unnecessarily to prevent 1 death. Finally, early PSA screening and the resulting cascade of events have significant cost implications.

This preliminary ruling of the USPSTF is still under review.

Why Is This a Game Changer?

Even without a final recommendation, the preliminary recommendation made headlines in newspapers, on television, and on the Internet. I have given talks about "the male ostrich," describing how many men avoid physicians and dismiss health concerns. Remember: Curable prostate cancer can present without symptoms or even findings on physical examination. It was not until public health campaigns raised greater awareness of prostate cancer screening that many men "pulled their heads from the sand" and became proactive about their health. The USPSTF recommendations could confuse patients, and we could lapse back into the pre-PSA era.

What Does This Mean for the Practitioner?

Patients are going to visit their healthcare providers and ask, "Should I have my PSA measured?" The clinician will need to know all the pros and cons of early detection as well as the latest treatment options, and will also need to be able to explain the option of "no treatment."

This is a complex cancer, and the treatment options range from close observation to total prostatectomy. The USPSTF recommendations and the resulting media frenzy have raised the bar for what clinicians must know and be able to explain to their patients.


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