Prostate Cancer Screening with Prostate-Specific Antigen Testing: More Answers or More Confusion?

Prostate cancer is a leading cause of morbidity and mortality among middle-aged and older men. Of the solid tumors prostate cancer is rather unique in that it presents in 2 distinct forms, a latent form, which grows slowly and poses no threat to the patient’s life, and an aggressive form, which metastasizes quickly and kills the patient. The discovery of prostate-specific antigen (PSA)2 and the demonstration of its utility for early diagnosis and monitoring of prostatic carcinoma have raised hopes that this simple serological test could be invaluable in screening asymptomatic individuals for early prostate cancer diagnosis. The premise is that such early diagnosis may then lead to early therapeutic interventions, which should improve the overall survival of prostate cancer patients. However, PSA screening of asymptomatic individuals has remained controversial during the last 15 years owing to the lack of evidence for improved patient survival. Recently, the results of 2 major randomized clinical trials on the effectiveness of PSA as a screening tool, from both the US and Europe, have been published. These results are not clear cut. For this reason, the controversy surrounding prostate cancer screening will likely continue for years. Below, we examine this issue with 4 authorities in the field. Patrick Walsh3 : Undisputed evidence for benefit! There is no debate that PSA testing has made it possible to diagnose prostate cancer at an earlier, curable stage. Because prostate cancer produces no symptoms until it is far advanced, before PSA testing most patients presented with incurable disease—either locally advanced or metastatic. However, following the advent of PSA testing, suddenly it became possible to diagnose prostate cancer at an earlier curable stage. According to data from the American Cancer Society, in 1990 only 68% of men presented with localized disease and 20.6% had metastatic disease. In …