Prostate cancer screening and the management of clinically localized disease

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f325 (Published 29 January 2013)
Cite this as: BMJ 2013;346:f325

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Prostate cancer is the most common cancer in men and claims over 10,000 lives in the UK every year (1). We agree the PSA test is far from perfect, which is why we do not support its use in a national screening programme, but it is currently the only available first step towards diagnosing the disease. For this reason we are concerned that the authors suggest that physicians should always advise men against having the test. Not all men with aggressive forms of the disease will have symptoms, therefore a number of these more aggressive cancers would fall under the radar if men with concerns were not offered the opportunity to have the test.

We recognise, however, that over-treatment should be avoided wherever possible. This is why our research strategy strongly focuses on establishing a better means of differentiating harmless and aggressive forms of prostate cancer and identifying men at high risk of developing aggressive disease. In the meantime, in the absence of more definitive tests, we urge physicians to heed the recommendations of the Prostate Cancer Risk Management Programme (2) and provide men with balanced information about the pros and cons of PSA testing. Men are entitled to make an informed choice according to their own situation - especially if they are at higher risk of getting the disease (3).

References:

1 Cancer Research UK http://info.cancerresearchuk.org/cancerstats/types/prostate/index.htm.

2 Prostate Cancer Risk Management Programme http://www.cancerscreening.nhs.uk/prostate/

3 Although less marked than the effect of age, black ethnicity and family history of prostate cancer remain significant risk factors. Johns LE, Houlston RS. A systematic review and meta-analysis of familial prostate cancer risk. BJU Int 2003; 91(9): 789-94.
Ben-Shlomo Y, Evans S, Ibrahim F, et al The Risk of Prostate Cancer amongst Black Men in the United Kingdom: The PROCESS Cohort Study. Eur Urol 2008; 53(1):99-105

Competing interests: None declared

Sarah Cant, Director of Policy and Campaigns

Prostate Cancer UK, Cambridge House, 100 Cambridge Grove, London W6 0LE

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We wish to add to the comprehensive review of prostate screening (1). Prior to considering the management of any potential malignancy, whether ‘over-diagnosed’ or not, a persistently raised PSA usually demands a tissue sample - most commonly obtained trans-rectally. However, such sampling is not only of questionable sensitivity in early stage disease, but may now also be becoming more detrimental (1-3).

Recently a medical colleague in our hospital underwent a trans-rectal biopsy with prophylactic antibiotic cover. 24 hours later he developed profound, life-threatening sepsis. The organism responsible was an E.Coli resistant to both fluroquinolones and aminoglycosides. Interestingly he had worked for over 30 years in a secondary care environment and had never personally taken antibiotics.

Evidence is fast emerging of the benefit of pre biopsy rectal cultures. Targeting prophylactic antibiotics dependent on gut flora resistance, we can decrease these harmful consequences (4), but is this a warning of things to come? Will targeted antibiotics only select out yet more resistant strains?

Furthermore, what effect does working in a medical setting have on our own gut flora? Are we at higher risk than the population at large and what extra precautions should be considered before carrying out ‘routine’ biopsies?

References:
(1) Wilt TJ, Ahmed HU. Prostate cancer screening and the management of clinically localized disease. BMJ 2013; 346: f325
(2) Onik G, Miessau M, Bostwick DG. Three-dimensional prostate mapping biopsy has a potentially significant impact on prostate cancer management. J Clin Oncol 2009;27:4321-6.
(3) Carignan A, Roussy JF, Lapointe V, Valiquette L, Sabbagh R, Pépin J. Increasing risk of infectious complications after transrectal ultrasound-guided prostate biopsies: time to reassess antimicrobial prophylaxis. Eur Urol. 2012 Sep;62(3):453-9.
(4) Duplessis CA, Bavaro M, Simons MP, Marguet C, Santomauro M, Auge B, Collard DA, Fierer J, Lesperance J. Rectal cultures before transrectal ultrasound-guided prostate biopsy reduce post-prostatic biopsy infection rates. Urology. 2012 Mar;79(3):556-61.

Patient consent obtained

Competing interests: None declared

Rhydian J Davies, CT3 Infectious Diseases

Brian M Stephenson FRCS, Meirion Llewelyn FRCP, Adam C Carter FRCS Urol, Elizabeth Kubiak

Royal Gwent Hospital, Royal Gwent Hospital, Newport, South Wales, NP20 2UB, UK

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4 February 2013

This is a great summary of the evidence. But recall Daniel Merenstein's JAMA article 'Winners and Losers':

http://66.199.228.237/mofo/pdf/evidence_based.pdf

Competing interests: None declared

Trish Greenhalgh, Professor of Primary Health Care

Queen Mary University of London, 58 Turner St London E1 2AB

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This article summarises well the evidence of role of surgery for localised prostate cancer. However in the article it states "No randomized trials have assessed mortality outcomes of external beam radiotherapy or brachytherapy versus other management strategies in men with PSA detected prostate cancer". This statement is incorrect as the PR07 trial in a randomised study of 1205 patients with localised prostate cancer showed a significant survival benefit of adding radiotherapy to hormone treatment of 74%vs 67% at seven years (1).

There is also another high quality trail published in the Lancet from Scandanvia showing a 10% improved survival at 10 years with the addition of radiotherapy to hormone treatment in men with localised prostate cancer.

These studies are the best evidence we have for the treatment of localised prostate cancer and supports the use of radiotherapy as a main stay for treatment of prostate cancer.

1)Lancet, Volume 378, Issue 9809, Pages 2104 - 2111,
2)Lancet, Volume 373, Issue 9660, Pages 301 - 308, 24 January 2009

Competing interests: None declared

Alastair B Law, Consultant Clinical Oncologist

Edinburgh Cancer Centre, Western General Gospital, Edinburgh

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An unknown affecting prostate cancer treatment decisions for younger patients is knowledge of the range of timescales for the disease to evolve. Molecular-clock techniques have recently determined timescales for the development of pancreatic cancer (Nature v467 p114 2010). Is application of these techniques not a 'future research need' for prostate cancer?

Competing interests: None declared

William Tobin, Retired University Lecturer

None, Vannes, France

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