Elsevier

European Urology

Volume 53, Issue 1, January 2008, Pages 37-44
European Urology

Review – Prostate Cancer
Screening for Prostate Cancer: An Update

https://doi.org/10.1016/j.eururo.2007.08.034Get rights and content

Abstract

Objectives

To review evidence regarding the potential introduction of prostate cancer screening programmes and highlight issues pertinent to the management of screen-detected prostate cancer.

Methods

Screening for prostate cancer is a controversial health care issue in general and urological practice. A PubMed database search was performed, followed by a systematic review of the literature, to examine the evidence base underlying prostate cancer screening.

Results

A prostate cancer screening programme should satisfy several key postulates prior to its introduction. To date, several of these postulates have not been satisfied, and the evidence available for prostate cancer screening is currently insufficient to warrant its introduction as a public health policy. The natural history of screen-detected prostate cancer remains poorly understood, and recent evidence suggests that a screening programme may detect a large number of men with indolent disease who may be subsequently overtreated. Several randomised clinical trials are currently in progress and it is hoped that they will provide robust evidence to inform future practice.

Conclusions

National systematic prostate cancer screening programmes outside randomised clinical trial settings have not been implemented to date owing to lack of robust evidence that such programmes would improve survival and/or quality of life in men with screen-detected disease. Forthcoming results of clinical trials and the application of appropriate risk stratification to prevent overtreatment of indolent prostate cancer are likely to change practice in coming years.

Introduction

Screening for prostate cancer is a controversial issue in health care in general and urological practice in particular [1]. The merits of introducing national prostate cancer screening programmes in Europe are currently being debated. At present, the evidence to support the implementation of national prostate cancer screening programmes is inadequate. These programmes have therefore not been introduced in a systematic fashion outside randomised clinical trial settings. Whilst policy appears uniform in Western countries, guidance differs. In the United States, guidance currently favours the principle of screening for prostate cancer. The American Cancer Society recommends screening for all men aged at least 50 yr, although it acknowledges that men should be educated about issues regarding early detection and prostate cancer treatment, thereby aiding full participation in decision making [2]. The American Urological Association recommends that healthy men over the age of 50 should consider prostate cancer screening with a digital rectal examination (DRE) and serum prostate-specific antigen (PSA) test [3]. We herein review the public health issues pertinent to introducing a prostate cancer screening programme whilst acknowledging that individual men and their physician may have a different perspective on PSA testing.

Section snippets

Principles of screening

“Screening” identifies preclinical and asymptomatic cases of a disease in a population at risk using a suitable test, rather than making a diagnosis based on a patient's presentation at a later stage with symptoms and signs. The natural history of cancer suggests that a malignancy or precursor lesion may be detectable in advance of the appearance of symptoms and signs during a “screen-detectable” preclinical period [4]. Population-based screening programmes aim to reduce cancer morbidity and

Future developments

Future developments are likely to impact on the potential introduction of prostate cancer screening programmes. Firstly, the results of the large RCTs currently in progress will have a major influence on the merits of introducing systematic prostate cancer screening programmes, and on the effectiveness of available treatment options. Secondly, there is an urgent need to develop a combination of methods for accurate risk stratification to target therapies more appropriately to those patients

Conclusions

In our era of “evidence-based medicine” and in the absence of sufficient data from RCTs, it is currently inappropriate to introduce mass screening for prostate cancer. Public health policy should follow the acquisition of adequate evidence to drive clinical practice, rather than yield to mounting pressures from the general public, the media, and some professional medical organisations to introduce screening outside the context of well-conducted research. Future advances will be guided by the

Conflicts of interest

The authors have nothing to disclose.

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