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Rebuttal: Should Canadians be offered systematic prostate cancer screening?

YES

Let’s be clear. We need to acknowledge at least one point: the introduction of systematic screening for prostate cancer substantially reduces the mortality rate from this disease in the population. And a correction needs to be made: the incidence of cancer detectable by systematic biopsy, regardless of the detection rate of the prostate-specific antigen (PSA) test, is 15% and not 60% as suggested by my opponents.¹ Rather than depriving men of the potential benefits of systematic screening, efforts should be made instead to minimize the collateral damage that can be associated with it.

We hope to reduce the number of unnecessary biopsies thanks to a new test, the PCA3 gene test, that detects cancerous prostate cells in the urine.² This test, which is more specific than the PSA blood test, also helps to identify patients at higher risk of having fatal cancer. Patients with a low-grade small-volume cancer (like many cancers detected through screening) are increasingly being asked to consider follow-up without treatment unless the cancer shows clinical progression.³ These patients are also the subject of clinical trials involving medications or changes to diet to minimize progression of the cancer. On the other hand, patients with higher-grade cancers should be treated with prostatectomy, as this is the only treatment that has been shown to reduce mortality by more than 50%.⁴ In fact, several population studies show a cancer mortality rate 2 to 3 times lower among patients treated with surgery than among those treated with radiation therapy.^5,6

When the surgery is performed by experts, the sequelae of impotence and urinary incontinence occur much less frequently than indicated by the rates reported in the Swedish study cited by my opponents.⁷ For example, fewer than 5% of patients experience incontinence over the long-term, and in most cases, this problem can be corrected with minor surgery. Finally, the inconveniences of screening can also be minimized thanks to treatment with 5- reductase agents (finasteride or dutasteride) that reduce the incidence of cancer by 25%¹ while preventing the complications caused by benign hypertrophy of the prostate and that make the PSA test much more accurate.

Footnotes

Competing interests

None declared

References

1. Thompson IM, Pauler DK, Goodman PJ, Tangen CM, Scott Lucia M, et al. Prevalence of prostate cancer among men with a prostate-specific antigen level =4.0 ng per milliliter. N Engl J Med 2004;350(22):2239–46.[Abstract/Free Full Text]
2. Fradet Y, Saad F, Aprikian A, Dessureault J, Elhilali M, Trudel C, et al. uPM3, a new molecular urine test for the detection of prostate cancer. Urology 2004;64(2):311–6. discussion 315–6.[Medline]
3. Klotz L. Active surveillance with selective delayed intervention: using natural history to guide treatment in good risk prostate cancer. J Urol 2004;172(5 Pt 2):S48–50. discussion S50–1.[Medline]
4. Bill-Axelson A. Radical prostatectomy versus watchful waiting. N Engl J Med 2005;353(12):1298–300.[Free Full Text]
5. D’Amico AV, Moul J, Carroll PR, Sun L, Lubeck D, Chen MH. Cancer-specific mortality after surgery or radiation for patients with clinically localized prostate cancer managed during the prostate-specific antigen era. J Clin Oncol 2003;21(11):2163–72.[Abstract/Free Full Text]
6. Albertsen PC, Hanley JA, Penson DF, Barrows G, Fine J. 13-year outcomes following treatment for clinically localized prostate cancer in a population based cohort. J Urol 2007;177(3):932–6.[Medline]
7. Steineck G, Helgesen F, Adolfsson J, Dickman PW, Johansson JE, Norlen BJ, et al. Quality of life after radical prostatectomy or watchful waiting. N Engl J Med 2002;347(11):790–6.[Abstract/Free Full Text]

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