Modern paradigms for prostate cancer detection and management

To the Editor: The article by Williams and colleagues1 is a narrative review of prostate cancer care from a urological perspective. However, developing recommendations for prostate cancer screening requires complementary perspectives, including population health, general practice, and the wider community.

Population‐based prostate‐specific antigen (PSA) testing to screen asymptomatic men for prostate cancer is not supported by the references cited by Williams and colleagues or by systematic reviews, which identify and account for bias.2 The Royal Australian College of General Practitioners (RACGP) has assessed the current evidence and has advised against prostate cancer screening.3 The RACGP guidelines specifically state that GPs have no obligation to offer prostate cancer screening, and advise against adding PSA to a battery of pathology tests. The RACGP and the National Health and Medical Research Council have developed information sheets drawing attention to the numbers of men with screen‐detected prostate cancers who would never know they had cancer if they had not undergone screening, as well as to the impotence, incontinence and bowel problems that prostate cancer diagnosis and treatment can cause, whether necessary or not.3,4

Between 42% and 66% of screen‐detected prostate cancers would not have been diagnosed without screening. Prostate cancer is discovered at autopsy in 36% of men of European ancestry and in 21% of Asian men aged 70–79 years.5 As Williams and colleagues note, prostate cancer screening can lead to earlier diagnosis of aggressive cancers, and modern techniques enable individualised patient‐centred treatment.1 However, for the men whose cancers would never have been detected without screening, any treatment is unnecessary and potentially harmful.5

Prostate cancer screening does not meet the aim of reducing overall mortality.2 After 11 years of annual screening, four of 1000 screened men compared with five of 1000 unscreened men have died of prostate cancer. Among the screened men are 87 cases with a false positive PSA test result, of whom 28 have complications of biopsy, including 0.5 extra heart attacks. Both groups have lost 190 men from all causes.3

Australia's GPs manage a growing demand for evidence‐based primary health care, and the RACGP supports them by developing standards and guidelines. These are based on unbiased approaches and, with the current evidence, they cannot recommend prostate cancer screening.3