Journal of the National Cancer Institute Advance Access originally published online on January 29, 2008
JNCI Journal of the National Cancer Institute 2008 100(3):223-224; doi:10.1093/jnci/djm295
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© The Author 2008. Published by Oxford University Press.
CORRESPONDENCE |
Response
Affiliation of author: Division of Urologic Oncology, University of Colorado Health Sciences Center, Aurora, CO
Correspondence to: E. David Crawford, MD, Division of Urologic Oncology, University of Colorado Health Sciences Center, Mail Stop # F710, PO Box # 6510, Aurora, CO 80045 (e-mail: david.crawford{at}uchsc.edu).
Dr Braillon expresses concern that my editorial comment is an "advertising slogan" for screening. In the editorial comment it is stated, "Screening for prostate cancer is controversial—some medical organizations support it and others are skeptical." These controversies led to the development of a large randomized clinical trial in the United States to determine the value, if any, of early detection of prostate cancer, the Prostate, Lung, Colorectal, and Ovarian Cancer (PLCO) trial. This very important randomized trial began in 1992. I don't see how he comes to the conclusion that this is an advertisement based on the above statement!
He expressed concern over the statement, "Men aged 50 years could combine a routine colonoscopy and prostate biopsy!" Prostate-specific antigen (PSA) and digital rectal examination are not perfect screening tests, and if men really want to know if they have prostate cancer, then this may be an option. From our prostate cancer prevention trial (1), 16.7% of men with a PSA of less than 1.0 ng/mL have prostate cancer, and 22.5% of the cancers detected were high grade.
Early detection efforts have turned the tide from diagnosis of more advanced disease to more local. Accompanying this trend is the discovery of a certain number of nonthreatening cancers. Dr Braillon's statement, "The main drawback of cancer screening is overdiagnosis," is true to some extent. That is why we are working on less invasive management techniques as well as surveillance and then intervening only for the patients who show signs of progression. We have instituted a large clinical trial of targeted therapy in which we treat only the cancer, not the entire prostate (2). This has been referred to as the male lumpectomy. Although a number of men are potentially overdiagnosed, nearly 30000 men will die of prostate cancer in the United States this year. The latter probably wish that they would have been the victims of overdiagnosis rather than underdiagnosis.
Drs Roobol and Schröder are correct and acknowledge my concerns that their manuscript is not the result of a randomized trial between 2 and 4 years of screening. If screening is determined to be worthwhile, then most men will not need to be screened every year, especially those with PSA values of less than 1.0 ng/mL (Figs. 1 and 2). This is what we reported years ago from the PLCO trial (3). I agree with the statement that biopsy is not 100% sensitive, but it is still the definitive way to diagnose prostate cancer. We need tests that are more specific and sensitive and then molecular markers to help us determine who needs treatment.
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REFERENCES
1. Thompson IM, Pauler DK, Goodman PJ, et al. Prevalence of prostate cancer among men with a prostate-specific antigen level 
4.0 ng per milliliter. N Engl J Med (2004) 350(22):2239–2246.
2. Crawford ED, Barqawi A. Targeted focal therapy: a minimally invasive ablation technique for early prostate cancer. Oncology (2007) 21(1):27–34.[Medline]
3. Crawford ED, Chia D, Andriole GL, et al. PSA testing interval, reduction in screening intervals: data from the prostate, lung, colorectal and ovarian cancer (PLCO) screening trial. Proc Am Soc Clin Oncol (2002) 21(Abstract 4).
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J Natl Cancer Inst 2008 100: 222.
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