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EAU Press conference: Screening for prostate cancer - What to tell men who consider to be screened? Версия для печати Отправить на e-mail

No European country has so far introduced screening for prostate cancer as a healthcare policy. Several countries, however, have developed policies which allow and finance the application of PSA-based screening upon individual request. As in the UK, careful upfront information on risks and benefits is mandatory.

Use of PSA-driven screening in European countries. Only very limited information is available on the use of PSA testing in European countries. Interview studies in the Netherlands conducted in 2001 and 2005 show an increase in PSA use over time amounting to 20 to 40% overall and in the age-group of 70 years and older. Within the European Randomized study of Screening for Prostate Cancer (ERSPC) the proportion of cancers which are by definition screen-detected is known (the T1c category). The figures vary between 11% and 50%. Clearly, in spite of the publicly acknowledged controversy around screening for prostate cancer, many men wish to undergo testing and find cooperation at the level of their family physicians that cooperate in determining PSA and subsequent diagnostic steps. It is unclear how well informed these men are about the potential risks and benefits. It seems desirable to establish easily understandable and validated information on risks and benefits. Cancer Research UK has taken such an initiative; the proposed text will be included in the presentation.

Men who decide to be screened take risks. As with any other screening procedure for any cancer, a number of risks can be clearly defined before any benefit becomes evident. Overdetection and overtreatment are the most important risks. With the screening regimen used in the ERSPC study, a PSA cut-off of 3 ng/ml and 4-yearly screening, overdiagnosis has been determined to occur in about half of the men who undergo screening. Overdiagnosis is defined as the diagnosis of cancer which would never during the lifetime of a man lead to clinically evident prostate cancer or to his death. Obviously, the side effects of treatment, which may include loss of urine and loss of erections, weighs more heavily in men with overdiagnosed cancers. Among the additional points of concern is the very low specificity of the PSA test, combined with a rectal examination which leads to negative (unnecessary) biopsies of the prostate in 70-80% of all men. In spite of emerging evidence that screening for prostate cancer can effectively prevent the deaths from this disease, it is too early at this time to establish a balance of risks and benefits.

Potential benefits of screening. A man in the age-group 55-70 who decides to undergo screening and who is found to have prostate cancer on biopsy decreases his chance of dying of the disease with respect to a man who doesn't undergo testing by somewhere between 30 and 56% based on recent evidence coming from the ERSPC study overall and of its Swedish partner, the Gothenburg Randomized Screening Trial. The Swedish data, which show the larger benefit, are based on a 14-year follow-up which is not available in the ERSPC study as a whole, were the follow-up period amounts to 9 years. 11-year data are pending and will be available soon. A 9- to 11-year follow-up is short with respect to all clinical trial experience gained with localized prostate cancer. A follow-up period of at least 15 years is mandatory. The mortality benefits just cited do not translate into an advantage in overall survival if the populations of the two trials as a whole are considered. - Next to the mortality benefit screening for prostate cancer may prevent the suffering which is associated to the clinical progression of prostate cancer in many men. The effect of screening on advanced prostate cancer with metastases is subject to an invited presentation at this meeting. The prevention of metastatic disease occurs in a similar order of magnitude as the decrease of prostate cancer mortality. Quality of life studies are underway but are probably premature because they consider the benefits seen at 9 years only.
How can screening for prostate cancer be improved? The most important goal of research should be to develop a marker substance which can be determined in the blood and which would predict more accurately the presence or absence of prostate cancer, specifically of aggressive prostate cancer. Unfortunately, it is unlikely that a marker which matches this qualification will be developed within a reasonably short period of time. Such substance should automatically lead to the avoidance of unnecessary biopsies of the prostate. Men with normal marker levels would not have a biopsy indication. As long as progress in this field has not been made, PSA remains important for the diagnosis of prostate cancer. Its negative effects (unnecessary biopsies, overdiagnosis, etc) can be modulated by using readily available risk modifiers such as the size of the prostate, the presence or absence of abnormalities palpable by rectal examination and visible abnormalities at ultrasound or MRI examinations. To achieve these goals, to avoid unnecessary biopsies, decrease the proportion of overdiagnosed cancers and selectively increase the detection of aggressive cancers, a prostate risk calculator was developed which is based on ERSPC data. This instrument also allows considering the change in risk after a previous negative screen and a previous negative biopsy. If prostate cancer is found, the latest segment of the risk calculator allows differentiating between potentially aggressive and indolent cancers. The risk calculator is available on both websites of the EAU. Based on a licensing agreement between the EAU and the owner, the Rotterdam Prostate Cancer Research Foundation (SWOP), a brief demonstration of the risk calculator will be given as part of the presentation during the press conference. The calculator is in the process of revision in order to make it more attractive and user friendly for lay men and for professionals.

Prof.dr. F.H. Schroder
International coordinator ERSPC, on behalf of the multinational ERSPC Study Group

Последнее обновление ( 06.07.2011 )
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