The golden rule: Do not do to others what you do not want done to yourself.

Abstract

Using the Surveillance, Epidemiology, and End Results database, Butler et al1 have calculated annual prostate cancer incidence rates from 2010 to 2015 and have shown that the incidence of localized disease has declined and that the incidence of distant metastatic disease has increased. They have suggested that US Preventive Services Task Force (USPSTF) 2012 grade D recommendations against prostate-specific antigen (PSA) screening may have affected the change. Is it meaningful that the proportion of advanced cancer has increased? The endpoint of the screening trial should be a reduction in mortality. Why did not they study mortality? Overdiagnosis, the identification of asymptomatic cancer that would never cause symptoms or contribute to death, is one of the most important harms of PSA-based screening programs. Even if advanced cancer increases, cancer mortality and overall survival do not change so much. That is what prostate cancer is. There have been 3 major randomized clinical trials (RCTs) for PSA screening: the Prostate, Lung, Colorectal, and Ovarian Trial,2 the European Randomized Study of Screening for Prostate Cancer (ERSPC),3 and the Cluster Randomized Trial of PSA Testing for Prostate Cancer.4 The data from these RCTs show that early cancers are more common in screening groups, that advanced cancers are more common in nonscreening groups, and that PSA screening has little impact on cancer mortality. Using the low-quality Surveillance, Epidemiology, and End Results database, Butler et al1 observed only a part of the overdiagnosis problem retrospectively. In their editorial comment, Joshi and Filson5 emphasize the “positive” data from ERSPC, which demonstrated a 20% reduction in prostate cancer mortality, and criticism of the Prostate, Lung, Colorectal, and Ovarian Trial concerning high levels of crossover between study arms. After the publication of the Cluster Randomized Trial of PSA Testing for Prostate Cancer in 2018, the USPSTF and a group of United Kingdom named MAGIC published the latest systematic reviews and guidelines.6-9 In both statements, the 20% reduction found in ERSPC was fully considered. Acknowledging the data showing an improvement from 5.4 deaths per 10,000 person-years in the nonscreening group to 4.3 deaths per 10,000 person-years in the screening group, the fact sheet states that it will escape from cancer death at 1/1000 and that there is a benefit, although it is small. After an evaluation of the crossover and adherence for each RCT, the recommendation has been determined to be moderate. The balance with harm with respect to examination and treatment should be determined by the person receiving the examination via shared decision making. The assessment is very reasonable, and there is no room for criticism. The authors of the article and the authors of the editorial comment seem to be unhappy with USPSTF recommendations, and the latter have even said, “Many researchers and clinicians have dedicated their professional careers to study and mitigate the risks associated with prostate cancer treatment. However, the USPSTF's decision ignored these nuances and the extensive work being done to mitigate these toxicities.”5 They should rather turn their attention to the efforts of future younger urologists and researchers with passion and energy heading in the wrong direction. In addition, they should think of the efforts of elderly men dealing with unnecessary surgery and radiation therapy, lost sexual function, urinary incontinence, and postoperative complications for negligible merit that cannot be realized for them. Furthermore, the efforts required to obtain the data regarding PSA screening (especially the 3 RCTs) and the USPSTF effort that examined them and created guidelines should be evaluated. In an article in the New York Times,10 Richard J. Ablin, discoverer of PSA, says that PSA screening is a profit-driven public health disaster and that the American Urological Association is “shameful” for recommending PSA screening. Shared decision making requires accurate and deep knowledge about the natural history of prostate cancer, surgery, and radiation therapy. It has the right research targets. Many academic urologists who have recommended PSA screening and have dedicated their professional careers to studying and mitigating the risks associated with prostate cancer treatment are more than 55 years old. Pioneers of radical prostatectomy are more than 80 years old. Fortunately, most of them are men and have a prostate gland. They are familiar with the risks and benefits of prostate cancer and its treatment. We can find out if they have actually undergone PSA screening in the last 5 to 10 years and have undergone active prostate biopsy and surgery. It would be easy for the American Urological Association, the European Association of Urology, and other major urological associations in the world to conduct such a survey. No specific funding was disclosed. The author made no disclosures.