Clinical oncology update: Prostate cancer: Is screening for prostate cancer the current gold standard?—“Yes”

Abstract

IT IS very hard to know what to do and what to think when considering the diagnosis and treatment of prostate cancer. All would agree that prostate cancer is a serious disease: it is the most frequently diagnosed major male cancer and the second or first leading cause of male cancer death in most Western societies. Clinical cancer of the prostate can only be cured if localised and then it is usually asymptomatic. Thus, decades ago a yearly digital rectal examination (DEE) was recommended for all men older than 50 years, but this strategy was not well accepted, and even when broadly applied, only a minority were cured [l]. Alternatively, all experts would also agree that prostate cancer often ‘appears’ innocuous. Among men older than 70 years who die of other causes, 30% are found to also have cancer of the prostate at autopsy-usually a tumour of ~0.2 mm3 and low grade cell type [2]. Also, it is widely believed in Britain and Scandinavia that apparent clinically localised carcinoma of the prostate (ALCaP) need not be treated until symptomatic and then only for palliation. Many centres have analysed their ‘watch and wait’ results and observed that at 10 years at least, they yielded the same quality and length of life as aggressive treatments [3, 41. Finally, preventive medicine experts have analysed the literature on ALCaP diagnosis and treatment outcomes, and, using decision analysis modelling, concluded that aggressive diagnosis and treatment (with radical prostatectomy or radiation therapy) are marginally beneficial, especially when quality of life adjustments are made, and are definitely not beneficial after the age of 70 years [5]. No wonder then that task forces in the U.S.A. and Canada concluded that DEE and prostate-specific antigen (ISA) testing should not be part of the adult preventive health examination because the evidence was discouraging or insufficient [6]. Also, the phrase “most men die with prostate cancer rather than of it” is now well known and the conundrum of Dr Willet Whitmore “when cure is possible is it necessary and when cure is necessary is it possible” [7] remains frequently