Prostate specific antigen for detecting early prostate cancer
BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b3572 (Published 24 September 2009) Cite this as: BMJ 2009;339:b3572
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10,239 men in the UK died from cancer of the prostate in 2007 (1),
the
second commonest cause of cancer death in males. The probability is that
similar numbers will continue to die early and unpleasant deaths from the
disease every year until the UK devises a satisfactory national screening
programme . The introduction of national screening is , legitimately, the
subject of intellectual debate and clinical trials , as reviewed in the
BMJ (2).
The limited supportive class 1 evidence currently available allows a
continuing negativity of messages to be dispensed to patients by
practitioners influenced by lower classes of evidence which , when allied
to
male diffidence about preventive health matters and the overstressed
risks of
impotence and incontinence, leads to poor decision making about personal
screening. What is forgotten is that the treatment of advanced prostate
cancer and death from the disease are the biggest causes of impotence in
affected men, not modern investigations and treatments.
It is hard to escape the perverse conclusion that the interests of the men
who
are not going to die from the disease are placed before those who will
suffer
and risk an early death from it. Is it really impossible for the UK to
move
forward? We know about the significant strengths of genetic factors in
influencing the risk of developing the disease (3)and ,if we are not
going to
have early general population screening, can we not take the logical
intellectual leap and introduce national targeted screening of high risk
males.
General population screening using a single absolute PSA value may very
well
not be the answer to the problem but it seems almost deceitful not to use
the
information already available to develop a more sympathetic approach
within
the NHS to screening for prostate cancer.
Yours sincerely,
Dr R D Hunter,
Consultant Clinical Oncologist, Manchester
1. Office for National Statistics, 2009 Mortality Statistics: Cause,
2007
2. Ilic D, Green S BMJ 2009;339;b3572
3. Johns, L.E. and R.S. Houlston, A systematic review and meta-analysis of
familial prostate cancer risk. BJU Int, 2003. 91(9): p. 789-94
Competing interests:
RDH has a family history of ca
prostate and has had a screen
detected cancer
Competing interests: No competing interests
The subtitle for the article on prostate cancer screening “Evidence
is inconclusive, so patient education and shared decision making are
essential” must be corrected.(1) No evidence for benefit after decade and
decade of clinical research. Hope is no longer justified. To be shorter:
No evidence for screening!
When someone asks me about prostate cancer screening, I just say: “I
won’t let them touch my prostate.”
The Journal used to provide answers more concise and useful for
practice. There are so many more conditions which may be more relevant for
patients’ education or shared decision.
1 Ilic D, Green S. Prostate specific antigen for detecting early
prostate cancer. BMJ 2009;339:b3572
Competing interests:
None declared
Competing interests: No competing interests
The PSA screening editorial defies the evidence
Dear Sir,
The papers on pages 784 and 793 of the October 3rd BMJ, and also the first
column of Dr Ilic's editorial in the same journal were very interesting,
but his conclusions are incongruous. It is as if, having summarised all
the evidence to date on the validity of PSA screening, it was decided to
ignore most of it and basically state that what we need is more research.
The more time we spend conducting more research the more men will continue
to be subjected to major interventions with the accompanying high risks of
serious complications including incontinence, impotence and even death (I
must admit to some bias here in view of the death of a close friend from a
massive pulmonary embolus on day 7 following radical prostatectomy,
recommended to him because of a raised PSA level - the pathology in
retrospect showed a prostate problem that would almost certainly never
have bothered him if left alone).
How could an editorial on this subject possibly avoid the conclusion
that seems now very clear from the evidence, namely that PSA screening
should be abandoned. It may continue to be useful in managing symptomatic
patients but surely it is now clear that it leads to substantially more
harm than benefit as a screening test for normal healthy men. We have
known for decades that prostate "cancer" can be found at autopsy in up to
80% of elderly men who have died of unrelated causes. In other words,
pathologists are currently incapable of predicting the prognosis for
clinical disease from microscopic appearances (again, not news). We now
know also from the large published trials that the "benefit" from PSA
screening lies somewhere between vanishingly small and non-existent
Yes, we certainly need the research focus to turn towards the
molecular biology of prostate "cancer" wherein a solution to this problem
may lie, but until then it is doing a serious disservice to men to state
the kind of timid and insipid conclusion of this editorial, rather than a
clear cease and desist recommendation on PSA screening.
Yours sincerely,
Charles J. Wright, MD,MSc,FRCS(C,E,Ed)
Consultant in medical and academic affairs,
program planning and evaluation
Suite 704, 211 St Patrick Street,
Toronto, Ontario,
Canada, M5T 2Y9
email: cjwright@rogers.com
Competing interests:
None declared
Competing interests: No competing interests