Oncology Prostate Cancer


The Evidence of Screening for Prostate Cancer versus Spontaneous Health Check-ups


Sven Törnberg Senior Consultant, Cancer Screening Unit, Oncologic Centre, Karolinska University Hospital


Abstract


Screening for prostate cancer is an attractive strategy aiming to reduce the problem with a very high number of men dying from the disease. If all cancers were cured, screening would not be needed. Unfortunately, the opportunistic testing that has been extensive for many years has not yet contributed to any effect on mortality, mainly because the purpose of such testing is to have health confirmed, not to detect early cancer. New results from randomised studies are optimistic in terms of reducing prostate cancer mortality and less pessimistic concerning levels of overdiagnosis and overtreatment. However, these results shall not be interpreted as scientific evidence for continuing recommendations to carry out opportunistic testing, as such testing mainly attracts low-risk individuals who end up being tested too frequently.


Keywords Prostate cancer screening, health check-up, opportunistic testing


Disclosure: The author has no conflicts of interest to declare. Received: 10 September 2010 Accepted: 30 November 2010 Citation: European Urological Review, 2010;5(2):27–30 Correspondence: Sven Törnberg, Department of Cancer Screening, Oncologic Centre, Karolinska University Hospital, S-171 76 Stockholm, Sweden. E: sven.tornberg@karolinska.se


There is a need for the medical profession and healthcare decision-makers to have an active attitude towards this problem. There is also a need to find strategies in the continuing struggle against this disease, with a high number of men still dying from prostate cancer. The question remains, which strategy is the best?


Prostate cancer is the most common cause of cancer death among men in many European countries and is therefore a serious health problem, both for the individuals concerned and the general population.1,2


The Changing Attitude Towards Screening Primary prevention can reduce the incidence of cancer, treatment improves survival and secondary prevention or screening for early detection of cancer in a curable phase has the aim of reducing mortality. Until recently, prostate cancer screening did not fulfil all the screening criteria formulated by Wilson and Jungner in the World Health Organization report in 1968.3


A major problem was lack of


scientific evidence that prostate-specific antigen (PSA) screening resulted in a decreased prostate cancer mortality at the time.


In 2009, the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial and the European Randomized Study of Screening for Prostate Cancer (ERSPC) were published.4,5


Both studies have been heavily


debated and a common consensus has been that due to the negative effects related to overtreatment of cancer cases that would never have been clinically relevant, organised and population-based prostate cancer screening programmes could not be recommended.


When the results from the recent Gothenburg trial were reported, suddenly a new scenario appeared.6


The Gothenburg trial showed an © TOUCH BRIEFINGS 2010


The first randomised controlled trial (RCT) on cancer screening was the Health Insurance Plan, a mammography study from New York. This trial was able to demonstrate that annual mammography screening in combination with clinical breast examination decreased breast cancer mortality by 30%.7


Furthermore, a total of seven RTCs


on breast cancer screening contributed to the knowledge that mammography screening leads to reduced breast cancer mortality.


27


effect on mortality that was twice as large compared with the ERSPC trial, which was the only trial in 2009 able to demonstrate an effect on mortality by screening. The reduction in mortality was 44%: 44 men out of 1,138 died of prostate cancer in the study group in comparison to 78 out of 718 in the control group. Moreover, the additional number of cases needed to treat – or diagnose, since not all cases were actually treated – was 12 (compared to the 48 additional cases needed to treat in the ERSPC). The survival rate increased from 89% in the control group to 96% in the study group. The increment in survival, in absolute numbers, equalled 34 cases.


The question is how to interpret these results and how to act on them? There is a lot to be learned from the experiences of other population- based screening programmes, which can be used as guidance.


The History of Cancer Screening in Europe The history of cancer screening in Europe goes back to the 1940s, when the Papanicolaou smear was introduced. The smear test was not only a non-invasive method to detect precursors of cervical cancer, but was also a health check-up; a way to confirm health and ensure that a woman did not have the cancer in question.


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