Indian Journal of Urology
COMMENTS
Year
: 2009  |  Volume : 25  |  Issue : 2  |  Page : 185-

Editorial Comment


 

Correspondence Address:




How to cite this article:
. Editorial Comment.Indian J Urol 2009;25:185-185


How to cite this URL:
. Editorial Comment. Indian J Urol [serial online] 2009 [cited 2021 Sep 18 ];25:185-185
Available from: https://www.indianjurol.com/text.asp?2009/25/2/185/52909


Full Text

Since this article was written, results of the analyses of the European Randomised Study of Screening for Prostate Cancer (ERSPC) [1] and the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (PLCO) [2] have been published.

The ERSPC results are based on a median follow up of close to 9 years in 72,952 men aged 55-69 who were randomized to screening and 89,435 men in the same age group who were randomized to control. In men randomized to screening 214 men died of prostate cancer whereas in the control group 326 men died. The incidence of prostate cancer was 8.2% in the screened population and 4.8% in the control group. There was a reduction in the incidence of advanced cancer in the screened group. The authors concluded that screening offers a 20% reduction from prostate cancer mortality. Though this sounds reasonable, in practical terms1410 men need to be screened and 48 men need to undergo radical treatment in order to save 1 life. One should not under estimate the harm done not only unnecessary biopsies, treatments and the profound anxiety burden on the part of the patient. The economic cost of this is very unlikely to favour routine screening. In spite of rampant use of opportunistic PSA screening, few Indian urologists would have managed more than 50 cases of localized prostate cancer in their lifetimes, which raises doubts over the use of this strategy in countries like India which have a low incidence of prostate cancer.

The PLCO analysis reported on a 7 year follow up of 38,350 men aged 55-74 yr who were randomized to control and 38,343 men randomized to screening. In this study there was no reduction in the incidence of advanced cancer at 7 years in the screened group. 50 men died of prostate cancer in the screened group and 44 in the control group. One of the flaws of this study was, a significant proportion of men (40%) in the control group had received pre-randomisation screening, which increased to 52% by year 6. Experts highlight that this 'contamination' of the control group could have led to decreased mortality.

These trials would be hotly debated in the years to come as there remain limitiations regarding the methodology used.

The major problem with these studies have been over-diagnosis and over-treatment.[3] In an era where active surveillance is emerging as a therapeutic option for favorable cases, it remains to be seen whether screening protocols would continue to offer the modest advantage as seen in the ERSPC study. Till such time it is imperative to develop and validate other biomarkers which could help to correctly identify high risk cases which would benefit from radical treatment, thereby avoiding unnecessary treatment and anxiety associated with over-diagnosis of indolent prostate cancer. Therefore, the PSA test should be used with caution in opportunistic screening and should not be physician initiated. Every effort should be made to explain its limitations and possible harm to patients.

References

1Schroder FH, Hugosson J, Roobol MJ et al. Screening and prostate cancer mortality in a randomized European study. N Engl J Med 2009;360: 1320-8
2Andriole GL, Grubb III RL, Buys SS et al . Mortality results from a randomized prostate cancer screening trial. N Engl J Med 2009;360: 1310-9.
3Holmberg L. Prostate cancer screeing: the need for problem solving that puts men's interests first. Eur Urol 2009;56:34-37.