Screening for prostate cancer--necessity or nonsense?

INTRODUCTION PROSTATE CANCER is a common disease among men above the age of 50 years. The 85 000 new cases diagnosed in the European Community every year amount to 13% of all cases of cancer in men. Prostate cancer in most countries is now the second most frequent malignancy in men after lung cancer. Death from prostate cancer accounts for 9% of all cancer death in males--this is evident from a recent review of prostate cancer incidence and mortality in European Community countries by M011er Jensenetal . [1]. The incidence and mortality of prostate cancer is also increasing in most Western countries. Part of this is due to the increase of male life expectancy. However, after correction for life expectancy, there remains a true increase, which at this moment is unexplained. This has been shown clearly in a recent survey in The Netherlands [2]. In 1982 Mettlin and co-workers [3] have published data from a shortand long-term survey of prostate cancer of the American College of Surgeons. Their data include the stage distribution in 20 166 (long-term) and 14079 (short-term) patients with this disease. Although their data may be biased by the inclusion of an unusually high proportion of incidentally detected, usually focal prostate cancer (23 and 27%), this study still shows that roughly half of patients who are diagnosed as having prostate cancer present with locally advanced and/or metastatic disease at the time of first diagnosis. The prognosis of patients with advanced prostate cancer, even with the most aggressive treatment, is poor. Cure is impossible, median time to progression and median survival of metastatic patients is in the range of 18 and 30 months, respectively [4, 5]. These figures contrast sharply with the results of radical prostatectomy or radiotherapy for localised disease, usually cancer that is palpable on rectal examination. Such data were recently subject to a United States National Cancer Institute (NCI) consensus development conference and the conclusion was that both radical prostatectomy and radiotherapy are "clearly effective forms of treatment" in this disease [6]. Median survival was shown by Gibbons [7] to be longer than 15 years in 57 patients with clinical stage B disease who were followed for more than 15 years. The observed crude survival rates were identical to the expected survival of 59year-old American men. Obviously, if a high risk for patients suffering from localised prostate cancer and effectiveness of treatment could be documented, a systematic search for early stages of prostate cancer should lead to a decrease of the mortality of this disease. However, uncertainties concerning the natural history, especially in the individual patient, and the lack of randomised treatment studies comparing radiotherapy or radical prostatec-