Prostate cancer screening and treatment: where have we come from and where are we going?

OBJECTIVE To evaluate the current prostate cancer screening and treatment paradigm in light of recently published long-term results of major screening and treatment trials. METHODS Historical review of the evolution of the diagnosis and treatment of prostate cancer followed by a detailed summary of the findings and differences among the three major screening trials and the three major treatment trials. RESULTS Prostate-specific antigen (PSA) testing can identify clinically significant prostate cancer and has produced a significant stage shift and is the likely explanation for the decline in prostate cancer mortality. Unfortunately, PSA testing predominantly identifies low-grade disease that is unlikely to progress during a patient's lifetime leading to substantial diagnosis of indolent disease. Treatment with radical prostatectomy (RP) appears to benefit primarily younger men (aged <65 years) with intermediate-grade disease. Too few men with low-grade disease benefit from RP to justify intervening in all. Unfortunately, high-grade prostate cancer often progresses despite surgery and radiation. CONCLUSION The primary PSA testing paradigm is wrong. Rather than attempting to identify all prostate cancers as early as possible, testing objectives should shift towards identifying men likely to harbour clinically significant disease. These are the men who appear to benefit from early diagnosis and intervention, including the earlier use of antiandrogen therapy prior to widespread metastases.