A different view, continuing the debate
3-5 PROSTATE CANCER: ARE WE SCREENING AND TREATING TOO MUCH?
We are in the midst of a vigorous and uncontrolled nationwide effort to detect prostate cancer and eradicate localized prostate cancer.
The American Urological Association Guidelines Panel for the management of clinically localized prostate cancer reviewed the same data as the authors of the ACP guidelines. The panel reported that the outcomes of treatments could not be compared because of extreme variations in the patient populations that had been assigned to watchful waiting vs invasive treatment. The mean age of patients assigned to radical prostatectomy was 63 years. The age of watchful waiting patients was 70 years, and many more patients assigned to watchful waiting had more differentiated PC. In addition, nearly all outcome data were based on patients with less than 5-year follow-up.
The editorialist concludes— " I believe the model they have proposed to estimate the risk-benefit ratio of screening for prostate cancer and treatment of localized disease is not reliable or particularly useful. I subscribe to the American Cancer Society recommendation that a man older than 50 years of age should have annual digital rectal examination directed at assessment of the prostate. I also support measuring the PSA level at baseline. If this level is low and the prostate is unchanged over time, the PSA measurement can perhaps be repeated in 2 or 3 years."
Annals Int. Med. March 15, 1997; 126: 465-67 Editorial from Univ. Of Utah School of Medicine, Salt Lake City

Comment:
The ACP recommends that physicians describe the potential benefits and known harms of screening, diagnosis, and treatment. This seems to imply that Drs. A, B, & C will present the same description. I doubt it. I believe the descriptions will differ according to the experience and biases of the individual clinician.
I believe it likely that selective screening for PC will eventually prove as beneficial in reducing mortality in the 50-60 year old range as is mammography. If costs and eventual risks of screening were low, screening would be justifiably widely applied. But, eventual costs and risks at present are high—much higher than for mammography.
Where to draw the line? No matter where, at present, more men will be harmed than benefited. A few will be cured at the expense of harm to many. The individual "cured" may also be grievously harmed. RTJ

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