The use of prostate specific antigen (PSA) screening for early detection of prostate cancer has been the subject of considerable debate. The screening may be of the general population, or limited screening of "at risk" populations, or, finally, case finding, with the screening being part of a routine medical check-up. Currently, for all three types of screening there are no randomised trials to determine whether PSA screening does more good than harm, or the converse. In particular, there is little evidence to support general population screening.³

What is the stance of national professional bodies in the face of this uncertainty? The American Cancer Society recommends annual PSA testing starting at age 50 for men with average risk for prostate cancer.⁴ Their guidelines, however, are not recommendations for public programs of mass screening, but are intended to help individual doctors and patients select the best early detection protocol for their personal needs. The American Urological Association also recommends annual screening with both digital rectal examination and PSA for men aged 50-70 years.⁵ On the other hand, the US Preventive Services Task Force recommends against screening,⁶ and in Europe the consensus is that widespread population screening cannot be recommended as a public health policy at present.⁷

What are the recommendations in Australia? The Australian Cancer Society⁸ and the Australian Health Technology Advisory Committee³ recommend against screening.⁴ The Urological Society of Australasia's current position is to recommend against population screening of asymptomatic men. However, they recommend that asymptomatic men aged 50-70 years (or between 40 and 70 years with a positive family history of the disease) who wish to be tested should be able to do so after appropriate counselling. They suggest that it is up to individual doctors to decide whether to advocate screening for a man not requesting it.⁹

What are the arguments for and against screening?
Those in favour of screening argue that even small tumours will eventually progress to metastatic disease if the patient lives long enough.¹⁰ In addition, most cancers detected by PSA-based screening are largely cancers expected from their volume and histological grade to progress.¹¹ There is also strong evidence to suggest that disease confined to the prostate is curable.¹² Furthermore, a recent population study with long term follow-up of almost 60 000 patients with clinically localised prostate cancer provided evidence that treatment in moderate and poorly differentiated tumours is superior to observation alone.¹³ Finally, PSA will detect organ-confined disease, and therefore potentially curable cancer, more frequently than digital rectal examination alone.¹¹

In this climate of uncertainty what are our general practitioners (GPs) doing? The Royal Australian College of General Practitioners recommends against screening.¹⁵ However, in a recent questionnaire survey of New Zealand GPs, most indicated that they currently screen at least some men aged 50 or more by digital rectal examination or PSA regardless of beliefs about test efficacy.¹⁶ This is probably explained by GPs' direct clinical responsibility and their greater concern with their patients' individual needs rather than with recommendations of public health and professional bodies.

What then is the community perspective? In this issue of the Journal, Ward et al. address the subject of male awareness of prostate cancer.¹⁷ In a randomly selected group of 340 men aged between 40 and 80, they showed that 22% of those aged 50 or more had been screened for prostate cancer within the previous 12 months. They also found that the men in this population overestimated their lifetime risk of developing and dying of prostate cancer. This is no doubt due in part to the widespread incidence of the disease, as well as a general fear of cancer and raised awareness resulting from increased media coverage.

From a public health viewpoint, the significant cost of prostate cancer screening would need to be offset by pos sible cost savings from an eventual mortality rate decrease. From an individual viewpoint, the detection of an asymptomatic organ-confined cancer (case finding) may be of substantial benefit. While the international medical community remain divided on this issue, and there is evidence for and against case finding, we believe that each man must participate in the screening decision and decide for himself. This decision is complex and must be made with full knowledge of the risks of contracting and dying from prostate cancer. The decision will be affected by the man's age and general health, and his particular risk category for developing prostate cancer. The opinions of his general practitioner and even the wishes of his spouse will affect his decision. He must be aware of the potential side effects of diagnosis and treatment, and understand that, in conservatively managed patients, if hormone therapy fails there is no further reliably effective treatment.

Ward et al. have shown that screening is occurring in the community, and they argue that accurate information is not being received by the community at large. They recommend that public health initiatives to discourage prostate cancer screening should focus particularly on men with bothersome urinary symptoms and those who worry about prostate cancer.¹⁷ While we agree that public education is essential, we believe this must neither discourage nor encourage screening by case finding, but rather give accurate, unbiased information to all men. The information must be balanced, as it has now been shown in several studies that patient preference regarding screening and treatment is greatly affected by this information.¹⁸

In the current climate of uncertainty, it is mandatory to include the patient in any screening decision. This is the recommendation of the Australian Health Technology Advisory Committee³ and the Urological Society of Australasia.⁹ When fully informed, men should be free to exercise personal preference regarding prostate cancer screening.

Phillip D Stricker
Urologist, St Vincent's Clinic, Sydney, NSW

David R Eisinger
Urologist, Concord Hospital, Sydney, NSW

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