Group Title: BMC Urology
Title: Prostate Cancer - To screen, or not to screen, is that the question?
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Title: Prostate Cancer - To screen, or not to screen, is that the question?
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Language: English
Creator: Rosser, Charles
Publisher: BMC Urology
Publication Date: 2008
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Abstract: There continues to be controversy regarding serum Prostate-Specific Antigen (PSA) and prostate cancer screening. We anxiously await the results of two large prospective randomized clinical trials (Prostate, Lung, Colon, and Ovary-PCLO screening trial in the US and European Randomized Study of Screening for Prostate Cancer-ERSPC in Europe) assessing the benefits of prostate cancer screening. However the true question to answer may be which cancer to treat and when should we treat it.
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Commentary


Prostate Cancer To screen, or not to screen, is that the question?
Charles J Rosser


Address: Department of Urology and Pharmacology and Therapeutics, University of Florida, Gainesville, Florida, USA
Email: Charles J Rosser charles.rosser@urology.ufl.edu


Published: 23 December 2008
BMC Urology 2008, 8:20 doi: 10.1 186/1471-2490-8-20


Received: 17 November 2008
Accepted: 23 December 2008


This article is available from: http://www.biomedcentral.com/1471-2490/8/20
2008 Rosser; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.



Abstract
There continues to be controversy regarding serum Prostate-Specific Antigen (PSA) and prostate
cancer screening. We anxiously await the results of two large prospective randomized clinical trials
(Prostate, Lung, Colon, and Ovary-PCLO screening trial in the US and European Randomized Study
of Screening for Prostate Cancer-ERSPC in Europe) assessing the benefits of prostate cancer
screening. However the true question to answer may be which cancer to treat and when should
we treat it.


After the introduction of serum PSA over 20 years ago as a
tumor marker for prostate cancer, controversy regarding
PSA and prostate cancer screening still abounds. First,
who should be screened? Second, does screening affect
mortality? Third, serum PSA used for screening has a low
specificity (~30%) thus a vast number of patients are
undergoing costly and invasive procedures to diagnosis
prostate cancer patients. Fourth, does screening lead to
over diagnosis and over treatment? These are just a few of
the controversial issues surrounding PSA and prostate
cancer screening.

It is clear that over the past decade, the utility of serum
PSA in diagnosing prostate cancer has declined [1].
Though still an important screening tool for prostate can-
cer, we have noticed a 'PSA migration' (i.e., heavily
screened populations are presenting with lower serum
PSA levels today compared to 10-20 years ago) [2].
Though serum PSA may not be the ideal screening tool, it
is the centerpiece of two large prospective randomized
clinical trials (Prostate, Lung, Colon, and Ovary-PCLO
screening trial in the US and European Randomized Study
of Screening for Prostate Cancer-ERSPC in Europe) assess-
ing the benefits of prostate cancer screening [3]. Though
we are lacking level I evidence demonstrating the benefit


of screening, we are engulfed in a sea of circumstantial evi-
dence associated with prostate cancer screening. First in
two large European studies, prostate cancer survival
improved in men who underwent prostate cancer screen-
ing and treatment compared to those who did not
undergo screening and/or treatment [4,5]. Similarly, in
the Olmstead County (Minnesota) study, routine prostate
cancer screening was associated with lower mortality rates
than in years prior to serum PSA testing [6]. Prostate can-
cer has held the dubious distinction for two decades of
being the second leading cause of cancer related deaths in
American men over the age of 45 years. However, since
the advent of PSA screening in the late 1980s, mortality
rates of prostate cancer have steadily declined for the past
decade. In 2008, it is estimated that 28,660 men will suc-
cumb to prostate cancer. This number is reminiscent of
prostate cancer mortality rates from the 1940-1970's [7].

Though routine prostate cancer is controversial, the con-
troversy is decreased when we consider screening in Afri-
can American men. African American men suffer
disproportionately from the disease, having a 50% higher
incidence and a 2-fold greater mortality than do Cauca-
sian men [8]. The reason behind this disparity is still
unclear. Researchers must determine if it is socioeco-


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nomic issues, access issues, or biological issues that are
creating this disparity. Unfortunately, it is unlikely we will
learn much about screening in individuals of African
descent from the European screening study, due to a low
accrual of individuals of African descent. Though the
numbers may be higher in the US screening study, we will
still be left analyzing a subset of the cohort and thus deal-
ing with data that may not be statistically robust. Until the
true culprit of this disparity is identified, continued edu-
cation and screening in hopes of early detection of pros-
tate cancer in African American communities should
continue.

Ultimately, however, I think the debate over prostate can-
cer screening is moot, since we have progressed beyond
advocating treatment for all prostate cancers. With the aid
of Partin Tables [9], Kattan Nomograms [10], assessing
PSA velocity[ 11] or percent of prostate cores positive for
prostate cancer [12], we continue to improve our ability to
diagnose low-grade, low-stage, perhaps non-lethal pros-
tate cancer that can be managed with expectant manage-
ment. Numerous studies have demonstrated the
feasibility of expectant management [13-15]. Expectant
management is a treatment option that is currently under-
utilized. Currently, there is an ongoing North American
trial not only assessing the utility of expectant manage-
ment, but also the ideal follow-up schema to ensure ade-
quate monitoring of disease (START, Surveillance Therapy
Against Radical Treatment, Laurence Klotz, principal
investigator). Thus I recommend vigorous recruitment to
this much needed trial that will provide treating physi-
cians and patients much needed information on expect-
ant management.

We are in the midst of the Information Age, where indi-
viduals realize that information or knowledge is power. In
fact in order to gain a competitive advantage, various
industry sectors are combing through reams and reams of
secondary data prior to making critical decisions. The
healthcare sector, specifically our patients, are no differ-
ent. Today patients already come to their physicians'
office after having done extensive research on the internet.
These patients crave information regarding their specific
condition. By having more information, patients are start-
ing to realize that they can make a more informed deci-
sion about their care and this is what was always at the
root of the prostate cancer screening dilemma.

Thus the true question is not whether we are going to
screen for prostate cancer, we have progressed past this
hurdle. The question of the day is when should we treat
prostate cancer. Unlike for prostate cancer screening, in
expectant management we do not even have significant
circumstantial evidence to support this concept. Thus we
anxiously await the results of the START trial assessing


expectant management. So let us not continue to roll
around in the quagmire of to screen or not to screen. Let's
instead embrace the notion and the current trial assessing
expectant management to answer the question, to treat or
not to treat.

Competing interests
The author declares that they have no competing interests.

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