PSA controversy: to screen or not to screen?

The decision was based on the conclusion that the benefits of screening were apparently outweighed by the subsequent harm done to men diagnosed with abnormal PSA values. Let’s review how the experts came to this conclusion and what can and should be done with the PSA during health check-ups.
Prostate cancer is the most commonly occurring cancer in men, accounting for almost one fourth of all male cancers. It is the third most common cause of death from cancer in men of all ages; one man in six will be diagnosed with prostate cancer in his lifetime but because some types of this cancer have a slow development, one in 30 will die from it. It affects mainly men around 70 years of age and is very rare before the age of 50.
Prevention is of course the best approach. But in some cases of slow cancer development, the therapy, which often involves surgery, radiotherapy, hormone-therapy and/or chemotherapy, has been found to outweigh the complications and side effects induced by the treatment, especially for older men. In addition, two large trials in Europe and the USA, have shown inconclusive results in how screening has reduced the mortality rate, with one demonstrating some positive effects and the second showing a negative outcome.
The risks associated with treatment of milder forms of cancer cases and the conflicting studies are the main reasons behind this controversy and the debate is still ongoing.
Those against the general PSA screening complain about over diagnosis and over treatment of many prostate cancer cases found through PSA testing. They argue that many low-risk patients could be managed with “active surveillance” and treated with medication only.
Specialists in favour of PSA screening consider that the PSA test currently remains the best tool to detect aggressive prostate cancer at the early stage, even if it means that some patients may experience unnecessary complications associated with diagnosis and treatment. They also stress the positive outcome of the European trial, which found a moderate yet significant reduction in absolute prostate cancer mortality. In addition, both Europe and the US have seen a significant decline in prostate cancer–specific mortality over the last two decades.
Today’s practice of medicine follows the results from the “Evidence based” studies. However, in the prostate cancer prevention, there is no consensus and the final recommendations for PSA screening have not been published yet due to the inconsistent clinical reports.
Without entering the debate on whether such trial outcome needs to be considered or not, some facts can nevertheless be highlighted in an attempt to clarify the issue:
First, there is no alternative to PSA today. Eliminating PSA would result in undiagnosed cancers spreading beyond the possibility to effectively cure the tumours.
Second, the risk of excessive treatment and subsequent harm could be minimised in directing patients to specialised prostate cancer centres where all treatment modalities could be thoroughly reviewed by an expert group.
Third, as recommended by most doctors, every male undergoing a health check-up needs to be informed about the risk and benefits of PSA screening and be involved in the decision-making process. After all, our health is our utmost personal concern.

Dr Gerard Lalande is the managing director of CEO-Health, which provides medical referrals for expatriates and customised executive medical
check-ups in Thailand. He can be contacted at [email protected].