Using Prostate-specific Antigen To Diagnose Prostate Cancer: Sailing in Uncharted Waters

In the United States, a man is diagnosed with prostate cancer every 3 minutes and death from the disease occurs every 15 minutes. This year, 35 000 men in the United States will die of prostate cancer, approximately 1 of every 4 who develop the disease. Although the number of deaths from other illnesses has decreased, the mortality from prostate cancer has risen during the last 5 years by 2.5% to 3% per year.

To reduce the number of deaths from prostate cancer, there are four approaches: primary prevention, early diagnosis, effective treatment of curable disease, and improved management of advanced disease. In the foreseeable future, it is unlikely that we will be able to prevent the disease by manipulating environmental or genetic factors or to cure patients with advanced disease while keeping morbidity at an acceptable level. Therefore, in order to reduce the number of deaths from prostate cancer, we are faced with the decisions of how far to go in diagnosing the disease and who should be offered treatment that may lead to cure.

In this issue of Annals, Kramer and colleagues [1] review the status of screening for prostate cancer. They point out that screening based on prostate-specific antigen (PSA) measurements may not be accurate and that the widespread adoption of such screening could lead to increased treatment-related mortality, reduced quality of life for patients who are treated, and a severe economic burden on the medical system. Thus, they believe that widespread screening for prostate cancer should await the results of their randomized study of screening. Looking at the same data from a different perspective, I draw different conclusions.

Are most men undergoing screening? Screening refers to a test done in an asymptomatic group of patients, and diagnosis refers to tests done in those who are symptomatic. …