2-5 THE SWEDISH PROSTATE CANCER PARADOX
In this issue of JAMA ("Fifteen-year Survival In Prostate Cancer " JAMA February 12, 1997; 277: 467-71), investigators from Sweden concluded that localized prostate cancer (PC) has a favorable outlook following watchful waiting, and that the number of deaths potentially avoidable by initial radical treatment is limited.
But Sweden has the 4th highest age-adjusted morality rate for PC in the world. If watchful waiting for localized disease results in fewer deaths why is this rate so high?
In the study, cases managed by watchful waiting occurred in men who were older (mean age 72), who had smaller tumors (47% non palpable) and more well differentiated tumors (66% grade I) than patients who underwent definitive therapy in the United States.
Across-the-board comparisons of outcomes between watchful waiting and early definitive therapy without careful consideration of all the subtle biases can be deceiving.
Advanced age limits the number of years patients are at risk for progression of the PC. Most older patients die with the disease rather than from the disease. But a high percentage of men younger than 65 with non-metastatic PC at the time of diagnosis die of the cancer.
There is a growing consensus that watchful waiting may be ideal for patients in selected circumstances: 1) Men who are too old or too ill to live 10 or 15 years, 2) Asymptomatic men in whom the tumor is too far advanced to cure, and 3) Some men with small well-differentiated tumors who elect to be observed.
Recent data suggest that efforts at early diagnosis and effective therapy may be paying dividends. In the US the mortality rate from PC fell 6% between 1971-90 and 1991-95. The decline was greatest in men younger than 75 in whom it fell 7%.
Recognizing that prostate cancer in most cases is a slowly progressing disease, it is reasonable to expect that the 70 year-old man who is dying of prostate cancer today was once a 55-or 60-year old man with clinically localized disease that was not diagnosed. Today it is possible to make an early diagnosis in many of these men. The challenge remains to identify those men who are most at risk of having their lives shortened by the disease.
JAMA February 12, 1997; 277: 497-98 Editorial from Johns Hopkins Univ. School of Medicine, Baltimore, MD

Comment:
No doubt screening men younger than 65 will lead to the discovery and cure in some. Overall, screening may lead to a slippery slope of adverse effects — anxiety, repeated tests and costs, surgical morbidity (and rarely mortality), impotence, incontinence.
There is always the possibility, even in men under 65, that the disease will be so slowly progressive that it will not cause death or morbidity. As noted, many will die with the disease and not of it. There is also the possibility that the cancer has spread outside the capsule at the time of discovery, and not be curable.
Detection and treatment of PC remains a large grey area. Patients should be informed and choose for themselves whether to be screened. I believe ordering a PSA routinely is bad practice. RTJ

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