COMMENTARY

Advances in Prostate Cancer: 2014

Gerald Chodak, MD

Disclosures

December 11, 2014

In This Article

Screening and Early Detection

The debate about the risks and benefits of screening for prostate cancer seems unending, with a major disconnect between what science has shown us and what many clinicians believe is the right thing to do. This year, the US Preventive Services Task Force reiterated its recommendations against routine screening for prostate cancer.[3] A Canadian task force has made a similar recommendation.[4] Both groups concluded that the benefits of screening are small at best, and they are outweighed by the harms. Both also acknowledge, however, that the recommendation not to screen men 55-69 years of age is based on somewhat flawed data, which results in less than robust conclusions.

Proponents of screening argue that screening has partly contributed to the significant decline in the death rate from prostate cancer and the lower incidence of metastatic disease at the time of diagnosis over the past 10 years, and therefore screening should continue to be offered. Proponents also contend that screening is not the problem; rather, it is the excess harm resulting from treating too many men with low-risk disease instead of placing them on active surveillance. Still others say that even if the benefit is negligible for the average man, screening should continue for high-risk individuals, such as African American men and those with a family history of prostate cancer. Unfortunately, that view is not based on any randomized data proving a benefit.

New data from Finland[5] challenge the belief that screening men with a family history is beneficial. Finland contributed the largest number of men to the European screening trial.[6] In a recent subanalysis of their results, investigators found that men with a family history of prostate cancer had an increased risk of being diagnosed with low-grade cancer but a decreased risk of being diagnosed with high-grade disease, compared with men with an average risk of developing the disease. Most important, after 12 years, screening these men did not improve overall survival or reduce prostate cancer mortality. These researchers concluded that men with a family history of prostate cancer are not more likely to benefit from screening.

The limitations of the study are that testing was conducted every 4 years, and the men underwent biopsy if the prostate-specific antigen (PSA) level was higher than 4 ng/mL or between 3 and 3.9 ng/mL and the free PSA level was less than 16%. Of course, longer follow-up may lead to different results. Unless other studies are conducted, the concerns about these results cannot be addressed. This study further demonstrates the importance of not making recommendations in the absence of supporting data.

Despite attempts to properly assess the impact of screening, limitations of all the studies have left us with inconclusive results, making counseling patients very challenging. For now, the best course of action is to explain the findings from the various studies so that men can decide what they want to do.

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