Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Prostate cancer screening under 50? A wrong and dangerous issue!
- Alain Braillon, Gérard Dubois (29 November 2007)
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Lack of methodology
- Judith A Strachan (30 November 2007)
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PSA screening of young men - Increasing the drama ?
- Stefano Ciatto (4 December 2007)
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Alain Braillon, Public Health. University hospital of Amiens. 80000. France, Gérard Dubois
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Alain Braillon MD, PhD and Gérard Dubois MD, PhD Public Health. University hospitals. Amiens. France braillon.alain@chu-amiens.fr Screening for prostate cancer after 50 is hardly acceptable because overdiagnosis is obvious and the impact on mortality remains unproven despite numerous trials for more than 15 years! All over the world, out of 19 major medical organizations, only the American Cancer Society and the American and the French and American Urological Associations recommend screening men for prostate cancer with annual PSA.1 Therefore, beside wasting resources, the issue raised by Lane et al will, unfortunately, be used to promote screening practice.2 Already in France, 36% of men underwent prostate cancer screening (un proven and not organized) whereas only 25% underwent colorectal cancer screening (proven benefit on mortality and organized). At the present time the only demonstrated consequence of prostate cancer screening is a 5 to 10% biopsy rate in the screened population with a risk of septicaemia and hemorrhage. Plus, for those treated, various adverse effects (impotence, incontinence, pain, rectal ulcers …). Lastly, “the recommendation from the American National Comprehensive Cancer Network (ANCCN) for screening for prostate specific antigen in men from age 40 …” cited by Lane et al to support their hypothesis is in fact a viewpoint from a single department of Urology. The ANCCN guideline is in fact a pro and con summary and describe screening after 40 in the category 2B (nonuniform NCCN consensus based on lower-level evidence including clinical experience, that the recommendation is appropriate).4 We crave for the publication of the consent form which was approved by the Trent multicentre research ethics committee. 1 Gignon M, Braillon A, Chaine FX, Dubois G. Le dépistage du cancer de la prostate : hétérogénéités des recommandations. Une exception française ? Can J Public Health. 2007;98: 212-6 2 Lane JA, Howson J , Donovan JL et al. Detection of prostate cancer in unselected young men: prospective cohort nested within a randomised controlled trial. BMJ, doi:10.1136/bmj.39381.436829 3 www.rochediagnostics.fr/htdocs/media/pdf/revues/echo_roche/off20/20_p6.pdf 4 http://www.nccn.org/professionals/physician_gls/PDF/prostate_detection.pdf Competing interests: None declared |
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Judith A Strachan, Consultant Biochemist Biochemical Medicine, NHS Tayside DD1 9SY
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It is disappointing in this otherwise interesting and important paper that there is no mention of the analytical methodology used in performing the PSA analyses and no clinical scientists are included as authors. It is vital to know in such a study which advocates a certain cut-off point whether all the blood samples were analysed in the same laboratory, using which equipment and what the performance characteristics of the method are. In addition, PSA is known to be elevated in the presence of urinary infection and can remain elevated after sexual activity - were these pre- analytical factors taken into account when recruiting the men for this study Competing interests: None declared |
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Stefano Ciatto, Head Dept. Diagnotic Imaging CSPO - Istituto Scientifico per la Prevenzione Oncologica, Viale Volta 171, 50131, Florence, Italy
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Suggesting at any level that screening by PSA for prostate cancer early detection may be beneficial is strongly inappropriate. In order to accept screening (and any other medical practice) as an ethical option, evidence of its efficacy (which is mortality reduction, not early diagnosis) is needed. This is not the case with PSA screening, in spite of at least 15 years of research. What has been successful with cervical, breast, and colorectal cancer (for which sound evidence of efficacy is available) is not yet achieved for prostate cancer, for which the only solid scientific evidence is that about half of screen detected cancers are overdiagnosed (that is were not bound to surface clinically in the lifetime in absence of screening) and, unfortunately mostly overtreated (with major unpleasant side effects). Indeed, this is probably the more harmful example of cancer prevention initiative that man has ever developed, with no proof, yet, that such harm is compensated by any evident benefit. The increasing practice of opportunistic PSA screening, in spite of adverse recommendations from most scientific authorities, and thanks to ignorant promoters and testimonials, is a good example of human schizophrenic behaviour in medicine. In such a context the paper by Lane and colleagues, although the authors are careful in interpreting observed data, may have a dangerous impact, in that it might convince some doctors that opportunistic screening age should be further reduced together with PSA cut-off. The study provides no reassuring data as compared to what is known for screened men over the age of 50 years: cancer detection rate at screening is quite high (2.3%), and although a selection bias (biopsies were not offered to all participants) can not be excluded, a rough estimate of prevalence/expected incidence ratio suggests a detection lead time in the range of that observed beyond age 50. Surprisingly, the issue of the longer high expectancy in younger men (which is likely to be associated to a lower overdiagnosis effect, but to a higher impact and more life-years of overdiagnosis and overtreatment related side effects) is not much debated. With the clear evidence that, in spite of contrary scientific proofs, the hysterical run for opportunistic screening will go on, based on the foolish assumption that “early diagnosis may only be beneficial”, even a feeble suggestion that such a fancy benefit may be offered also to men at age 45-49 may have dramatic consequences. The authors do not openly claim for PSA screening at any age but, based on their study evidence, some prophet will probably show up suggesting to reduce the starting age of opportunistic screening. And since this will not be done within the channels of the scientific debate, but through uncontrolled media, the effects might be unpredictable. Competing interests: None declared |
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