Prostate Cancer: Are We Screening and Treating Too Much

The incidence of newly discovered prostate cancer has increased substantially during the past decade. The old and standard digital rectal examination has been supplemented by widespread measurement of prostate-specific antigen (PSA) in men who are about 50 years of age or older. Measurement of PSA has clearly been a major factor in the increase in cancer detection. Transrectal ultrasonography of the prostate is widely done in hospitals, clinics, and urologists' offices if cancer is suspected on the basis of induration or a nodule in the prostate, an elevated PSA level, or both. Although ultrasonography of the prostate has been disappointing in cancer detection, ultrasonography-guided biopsy of the prostate done using a biopsy gun is now commonplace; this type of biopsy can be done in a clinic or physician's office and does not require anesthesia. The standard procedure is to obtain a biopsy specimen from any suspicious region of the prostate and to obtain sextant biopsy specimens (tissue cores from the base, middle, and apical area on each side of the prostate). If cancer is present in these specimens, we can determine the Gleason grade, estimate how much of each core is cancerous, and ascertain the number of cores that contain the cancer. The prostate is thus histologically sampled, but the estimate of tumor volume derived from these biopsy data is far from perfect.

Methods for the detection of early prostate cancer have certainly improved, but is this a good thing? It has been argued that aggressive cancer detection is expensive and meddlesome and leads to the overtreatment of tumors that may be indolent or at low risk for significant progression. In the background paper [1] that accompanies the American College of Physicians guidelines on screening for prostate cancer in this issue [2], Coley and colleagues point out that digital …