Areas of Uncertainty
A medical Doctor from the Departments of Medicine and Family and Community Medicine, University of New Mexico faces an apparently common problem exposed below:
The answer is far more complex than it appears at first glance:
Screening for Prostate Cancer
Is it useful? but overall is it safe ? Prostate biopsies can lead to death by septicemic shock in those days of increasing resistance to antibiotics. The questions rises more and more interest among men of fifty years of age and over. A recent article in the New England Journal of Medicine, the well known scientific medical journal, describes the state of the art. First of all we must keep in mind that not one prostate cancer equals another in term of prognostic and treatment. In the prostate area, cancer cells don’t necessary mean immediate treatment nor life threat. If screening is useful automatic treatment is not, at least not in all cases. The key word is: watch full waiting (or armed surveillance) in numerous of cases which only the urologists are skill to differentiate. Passed an age that the urologist has to determine given the co morbidities in presence, active treatment would bring more harm and adverse events than positive results.
One thing is granted for sure and has always to be kept in mind: prostate cancer is the second man killer just behind lung cancer. In the fight against this sort of killer primary cares Doctors, surgeons and epidemiologists have still a long uneasy road ahead to ride… and patients have to be patient and above all thing well educated and informed.
Anyway some searchers inferred that mathematically PSA screening should have played a role in 45% to 70% of the overall decline of prostate cancer deaths observed since 1994 but this didn’t resulted from a high level of proof study (not a randomized control trial).
18. Etzioni R, Tsodikov A, Mariotto A, et al. Quantifying the role of PSA screening in the US prostate cancer mortality decline. Cancer Causes Control 2008;19:175-81.
Randomly Controlled trials failed by two times to prove that a decline in overall mortality was attributable to screening. But the maximum follow-up is only 9 years. We can not exclude that a favourable effect can still happen beyond 10 year.
24. Holmberg L, Bill-Axelson A, Helgesen F, et al. A randomized trial comparing radical prostatectomy with watchful waiting in early prostate cancer.N EnglJ Med 2002;347:781-9.
According to other searchers 23 to 42 % of screened prostate cancers wouldn’t have cause neither any clinical problem nor the death of the patient during the remaining life time of the patient. Said differently 23 to 42 % of screened cancer were over diagnosis (which is not the same as false diagnosis).
23. Draisma G, Etzioni R, Tsodikov A, et al. Lead time and overdiagnosis in prostate specific antigen screening: importance of methods and context. J Natl Cancer Inst 2009;101:374-83.
Read the entire paper here: nejmcp1103642
What to do when a screening by PSA turns to be positive is a current dilemma in primary practice. Thanks to new technologies alternatives to radical prostatectomy exist: Focal cryotherapy also called Focal cryoablation.
These technique, coming from the USA, is beginning to be available in France.
I retrieved three articles you can read about it:
This technique seems to have a 80 percent rate of return to potency (vs 35 percent for surgery) according to the authors of one of the study.
Dr. Herb Riemenschneider of Riverside Urology in Columbus, Ohio, tell us more in this video.
The US Preventive Services Task force does not recommend the screening for Prostate Cancer by PSA.
The US preventive services task force is in charge by US law to evaluate preventive services in primary cares. Its latest recommendation gives a bad grade to Prostate cancer screening by PSA. It is graded at the D level which means that the scientific panel discourages the use of the preventive service that is evaluated.
In France a public health practitioner, Dr Braillon, from Amiens, a city north of France, arises concern about the high level of individual screening with PSA which is practically as high as an organised screening program. In a letter to the editor of “La Presse Médicale” of january 2011 he warns against such a trend saying that, in 2007, more than 5 Millions of tests by Prostatic Specific Antigen (PSA) have been undergone by French people.
In the US the issue is intensely debated between pros and cons of an organised screening program. A synthesis of the different positions is published by Kaiser Health News in its press review.
Image via Wikipedia