COMMENTARY

When to Screen, Biopsy, and Treat Prostate Cancer

Andrew J. Vickers, DPhil; Sigrid V. Carlsson, MD, PhD

Disclosures

June 18, 2013

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In This Article

Who Should Be Screened?

Andrew J. Vickers, DPhil: Hi. I'm Dr. Andrew Vickers of Memorial Sloan-Kettering Cancer Center, here in San Diego at the 2013 American Urological Association (AUA) Annual Scientific Meeting. Joining me today is Dr. Sigrid Carlsson. Dr. Carlsson comes from the University of Gothenburg but has been working with us at Memorial Sloan-Kettering Cancer Center for the last couple of years, looking at prostate-specific antigen (PSA) screening.

Dr. Carlsson, for many years, there has been this somewhat sterile debate: Does screening work? Does it not work? Should we screen? Should we not screen? What are the results of the large European trial, and how do they inform that question?

Sigrid V. Carlsson, MD, PhD: As an investigator of the European randomized study of screening for prostate cancer, our study[1] has clearly shown that screening is beneficial in terms of reducing prostate cancer mortality. We have seen a mortality reduction of 21%-44% in men who were screened. On the other hand, we have the side effects, the risk for overdiagnosis and overtreatment, so that is where we have the balance between harms and benefits.

Dr. Vickers: So we have a benefit from prostate cancer screening, reduced risk for prostate cancer death. We have these harms, unnecessary treatment and all the side effects that we get from treatment. What are the major influences that would shift the ratio of benefits to harm?

Dr. Carlsson: To improve this balance between harms and benefits, we came up with 4 simple rules of thumb: (1) Screen those who need to be screened (screen the right people); (2) biopsy the right people; (3) treat the right people; and (4) if men need treatment, do it at high-volume centers.

Dr. Vickers: Is there evidence right now in the United States that the wrong people are being screened?

Dr. Carlsson: Yes, certainly. There has been an overuse of PSA testing in men who are over the age of 70 years, men who have comorbid conditions, and who have other cancers, such as lung cancer or pancreatic cancer. Those men should not be screened.

Dr. Vickers: Because they have a very short life expectancy, and prostate cancer is a slow-growing disease.

Dr. Carlsson: Correct.

Dr. Vickers: Even if they have a PSA test and discover that they have prostate cancer, they are very unlikely to have any harm from that prostate cancer. A lot of the wrong men are being screened.

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