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Rebuttal: Should Canadians be offered systematic prostate cancer screening?

NO

We agree that the reason for systematic screening is the severity of the disease, having an effective method of early detection, and the availability of an early treatment that has a substantial effect on mortality rates. In 2007, however, informed consent to participate in screening is essential. To obtain informed consent, all the conclusive evidence on the risks and benefits of screening must be clearly presented. We did this in our article.¹

Increasingly, the use of the prostate-specific antigen test is being questioned. Several recent studies and reviews have discussed the important limitations of this marker both for detection of the disease and for making a prognosis for patients with prostate cancer.^2–6

Treating localized cancer with prostatectomy has only a modest effect on mortality from prostate cancer.⁷ The reduction in mortality, expressed only in relative terms (reduction of 50%), is misleading and not useful for communicating the facts to patients. As described in our article,¹ of 100 patients who underwent prostatectomy and were followed up after 10 years, only 5 had actually benefited from the procedure, and 95 had undergone the procedure for nothing and had risked having serious side effects!

It is too early to attribute the drop in the mortality rate due to prostate cancer in certain populations to screening. Without the results of the randomized clinical trials currently under way, the inadequacy of the data supporting systematic screening is repeatedly mentioned—with good reason.^4,8,9

While we are aware that certain men could benefit from early detection of prostate cancer, we cannot dismiss the negative effect of detecting "low-risk" cancers in otherwise healthy men. Unfortunately, it is not possible to tell patients who plan to undergo prostate cancer screening whether it would be more advantageous than disadvantageous to do so. Simply making a diagnosis of prostate cancer negatively affects their quality of life.¹⁰

In light of what we know, systematic screening for prostate cancer is not justified. Our role consists of clearly communicating the benefits and risks associated with screening to our patients, taking their values and preferences into account, and ensuring that they understand the potential consequences of their choices. In this way, we help them to make decisions they are comfortable with, regardless of the outcome. This is a proven approach.¹¹

Footnotes

Competing interests

None declared

References

1. Labrecque M, Légaré F, Cauchon M. Should Canadians be offered systematic prostate cancer screening? No [Debates]. Can Fam Physician 2007;53:989–92. (Eng), 994–7 (Fr).[Free Full Text]
2. Thompson IM, Ankerst DP, Chi C, Lucia MS, Goodman PJ, Crowley JJ, et al. Operating characteristics of prostate-specific antigen in men with an initial PSA level of 3.0 ng/ml or lower. JAMA 2005;294(1):66–70.[Abstract/Free Full Text]
3. Thompson KE, Hernandez J, Canby-Hagino ED, Troyer D, Thompson IM. Prognostic features in men who died of prostate cancer. J Urol 2005;174(2):553–6. discussion 56.[Medline]
4. Postma R, Schroder FH. Screening for prostate cancer. Eur J Cancer 2005;41(6):825–33.[Medline]
5. Welch HG, Schwartz LM, Woloshin S. Prostate-specific antigen levels in the United States: implications of various definitions for abnormal. J Natl Cancer Inst 2005;97(15):1132–7.[Abstract/Free Full Text]
6. Constantinou J, Feneley MR. PSA testing: an evolving relationship with prostate cancer screening. Prostate Cancer Prostatic Dis 2006;9(1):6–13.[Medline]
7. Bill-Axelson A, Holmberg L, Ruutu M, Haggman M, Andersson SO, Bratell S, et al. Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med 2005;352(19):1977–84.[Abstract/Free Full Text]
8. Ilic D, O’Connor D, Green S, Wilt T. Screening for prostate cancer. Cochrane Database Syst Rev 2006;3:CD004720.[Medline]
9. Harris R, Lohr KN. Screening for prostate cancer: an update of the evidence for the US Preventive Services Task Force. Ann Intern Med 2002;137(11):917–29. Available from: http://www.ahrq.gov/clinic/3rduspstf/prostatescr/prostaterr.htm. Accessed 2007 June 11.[Abstract/Free Full Text]
10. Korfage IJ, de Koning HJ, Roobol M, Schroder FH, Essink-Bot ML. Prostate cancer diagnosis: the impact on patients’ mental health. Eur J Cancer 2006;42(2):165–70.[Medline]
11. O’Connor AM. Using decision aids to help patients navigate the "grey zone" of medical decision-making. CMAJ 2007;176:1597–8.[Free Full Text]

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