Prostate Cancer Screening

Cancer has been one of the leading causes of death in the Western world for several decades and is responsible for great suffering in the sick and people around them. What we know today, with the resounding evolution of medicine in the last 40 years, is that many of these diseases have a cure, especially if they are found in time.

The most important issue when we talk about cancer is the moment, in the evolution of the disease, when the diagnosis is made, that is, in which we know that it exists. All these diseases begin by being a simple microscopic cell that for some reason is different from the others. At that time, and over a long period, cancer is no more than a set of multiplying cells, harmless enough and small enough to be easily treated. The problem is when it ceases to be harmless, progresses and spreads, ceases to be curable and the symptoms begin, causing suffering and culminating in the fatal outcome. As the moment of diagnosis is so decisive for a good result in the treatments came screening programs such as breast cancer, colorectal cancer, among others.

Prostate cancer is the most diagnosed cancer in man, with 417,000 new cases and 92,000 deaths in Europe each year, making it the second leading cause of cancer death. This is therefore a problem of great magnitude, with a huge impact on the health of our communities and which will tend to grow with the aging of the population.

A randomized European study on prostate cancer showed a 21% reduction in mortality with screening, which is equivalent to preventing the death of one man in every 781 screened and 1 in 27 of cancers detected. More impressively, if screening is continued over time, it is enough to track 101 men and detect 13 cancers to prevent a death. These figures show better results than in breast cancer or colorectal cancer screenings.

Despite this overwhelming evidence, the medical community remains historically divided, largely because of the risk of overdiagnosis and potential overtreatment. Overdiagnosis consists in the detection of cancer in patients who are asymptomatic and who will not develop symptoms during the remaining life period. This risk is real and requires a good look at the scope of possible generalised screening.

However, the implementation of health policies contrary to these data have proved disastrous in the United States of America where the trend towards an increase in mortality from aggressive forms of prostate cancer has been a reality in recent years.

The argument for overtreatment is due to complications associated with local treatment, namely urinary incontinence and erectile dysfunction. In this area, as in many others, the evolution has been enormous and today we have the possibility of performing less invasive surgeries with better technical precision, such as laparoscopy and robotic surgery. There is still a long way to go before effective treatment can be ensured free of adverse effects, but it is neither fair nor serious to acknowledge that it has evolved and that better results can be ensured today.

Further research may need to be used for various imaging tests, a detailed laboratory study or even a urodynamic examination. The latter is the ‘gold standard’ of functional bladder evaluation allowing, in most cases, a complete clarification of the causes and circumstances in which urinary losses occur.

When we talk about prostate cancer screening we talk about psa blood test (Prostate Specific Antigen). Isolated of little clinical interest, if measured serially can raise the suspicion of prostate cancer and initiate diagnostic gait. The European Urology Association recommends a first assessment between 40 and 45 years and subsequent assessments depending on the risk of the individual. Generally speak of an annual analysis from the age of 50 and which should be extended until the average life expectancy is less than 10-15 years.

Finally, the way to reconcile these different approaches must always be that of the best information and never that of ignorance. Not knowing the value of PSA so as not to run the risk of overtreating and inducing side effects is to accept the risk of detecting prostate cancer too late and seeing mortality increase. In my opinion it is not acceptable.