Prostate Carcinoma. Current Dilemma of Urooncology. How to Help the Needed and not to Harm the Others

Abstract

There is a remarkably rising incidence of histologically proven prostate cancer since the introduction of prostatic specific antigen (PSA) test into clinical practice. TNM classification of these tumors in about 50% of cases is in categories T1,2 N0M0, Gleason score 7 and PSA level under 10 ug/ l (Graph 1). Such tumors are considered low risk and therefore conservative approach seems to be acceptable therapeutic variant. In spite of nonsurgical approach, patients with the so called early stage diagnosed disease have been almost only indicated for radical prostatectomy with a therapeutic approach. More than 2,100 men underwent radical prostatectomy (RP) in the Czech Republic in 2009 but mortality curve remained unchanged for years (Graph 2). The largest study (ERSPC) looking for influence of PSA screening on mortality, involving 182,000 men, of which 162,000 were valuable for analysis, really lowered mortality. After 11 years, in the screened arm (PCA arm) mortality decreased by more than 20% in the screened arm (PCA arm) when compared with unscreened arm. But to save one life, 1,410 patients had to be screened and 48 of them underwent RP. But ERSPC results (and those similar from eg. PLCO study) gave a rise of speculation if all early detected tumors are indeed candidates for surgery (overtreatment), even if such intensive PSA screening is reasonable (overdiagnosis). In last decades, results of several studies support an opinion that low risk tumors diagnosed in men over 68 years, with several co morbidities and in less favorite health status would not be proper candidates for conservative approach (active surveillance or watchful waiting). As a consequence of these considerations, a question arises whether selected PSA test should not be more reasonable. In such a case, a patient should thoroughly discuss what profit the PSA test brings to him with his doctor.