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American College of Preventive Medicine Practice Policy. Screening for Prostate Cancer in American Men
0022-S347~6214%4Kl
Vol. 162,264-284, July 1% Printed in U.S&
TERJOUBNM. OF U ~ L O G Y Copyright 8 1999 by AMERICAN UR0uw;lclu.AssocunoN, hc.
ABSTRACTS BENIGN A N D MALIGNANT NEOPLASMS OF PROSTATE American College of Preventive Medicine Practice Policy. Screening for Prostate Cancer in American Men
R. FERRINIAND S. H. Woou, American College of Preventive Medicine, Washington, D. C. h e r . J. Rev. Med.,15: 81-84, 1998 Based on a review of the current literature and recommendations, the American College of Preventive Medicine presents a practice policy statement on screening for prostate cancer in American men.
Editorial Comment: With time there has been a gradual decline in opposition to prostate cancer screening. For example, these authors admit that prostate cancer is a significant and growing cause of morbidity and is not amenable to primary prevention. Although they do not recommend routine population screening, they state that men 50 years old or older with a life expectancy of greater than 10 years should be given information about the potential benefits and harm of, and be allowed to make their o w n choice about screening. Patrick C. Walsh, M.D. Evaluation of the Digital Rectal Examination as a Screening Test for Prostate Cancer F. H. SCHRODER, P. VAN DER MAAS,P. BEEMSTERBOER, A. B. KRUGER, R. HOEDEMAEKER, J. RIETBERGEN AND R. KRANSE ON BEHALF OF THE ROTTERDAM SECTION OF THE EUROPEAN RANDOMIZED STUDY OF SCREENING FOR PROSTATE CANCER, Department of Urology, Academic Hospital, and Institutes of Public Health and Pathology, Erasmus University, Rotterdam, The Netherlands J. Natl. Cancer Inst., 9 0 1817-1823, 1998 Background: The utility of digital rectal examination (DRE) as a screening test for early detection of prostate cancer has not been established. Therefore, we evaluated the usefulness of DRE as a stand-alone screening test and in conjunction with measured serum prostate-specific antigen (PSA) levels of 0 -3.9 ng/mL and transrectal ultrasonography (TRUS). Methods: Our study population consisted of 10,523 men aged 54-76 years who were randomly assigned to the screening arm of the Rotterdam, The Netherlands, section of the European Randomized Study of Screening for Prostate Cancer. The underlying prevalence of detectable prostate cancer was estimated by logistic regression analysis and used for calculating the sensitivity of DRE as a test. Pathologic characteristics of 105 radical prostatectomy specimens were used to determine the aggressiveness of the tumors diagnosed (and missed) by DRE. Results: The overall detection rate for prostate cancer in this population when serum PSA measurement, DRE, and TRUS were used was 4.59'0, and the detection rate with DRE alone was 2.5%. The positive predictive value of DRE ranged from 4% to 11% in men with PSA levels of 0-2.9 ng/mL and from 33% to 83% in men with PSA levels of 3.0-9.9 ng/mL or more. Most tumors detected by DRE in men with PSA levels of less than 4.0 ng/mL were small (mean volumes = 0.24-0.83 mL), and most were well differentiated (Gleason scores of 6 or less). Minimal, moderate, and advanced cancers were seen in 42%, 42%, and 16% of men, respectively, with a PSA level of 4.0 n g / d or less. DRE alone allowed detection of 264 (55.8%) of 473 cancers; 82 (17.3%) of the 473 cancers would have remained undetected by PSA-based screening alone (i.e., no follow-up procedures for PSA values of 0-3.9 ng/mL). Conclusions: For PSAvalues of 0-3.9 ng/mL, the positive predictive value and sensitivity of DRE, tumor volume, and tumor grade were strongly dependent on PSA level. DRE has a poor performance in low PSA ranges. Editorial Comment: This article is well done. However, the conclusions of the authors puzzle me. In patients with prostate specific antigen (PSA) less than 4 ngJml. the specificity of digital rectal examination for these trained observers was 90%, which is the highest ever reported. Also, the positive predictive values were identical to the recent study from Washington University in which those authors concluded "the positive predictive value of suspicious digital rectal examination was appreciable in men with low serum PSA. The majority of cancers detected by digital rectal examination had features of clinically important and potentially incurable disease."' Schroder et al state that many of the cancers detected in men with PSA less than 4 ngJml. did not show characteristics of aggressive tumor. However, when one looks at the data, in men with PSA 0 to 1the average tumor volume was greater than 0.2 cc and in those with PSA 2 to 2.9 and 3 to 3.9 Gleason scores were 7. I would reverse the conclusions of the authors and state that in men with low PSA digital rectal examination has a high specificity and is a valuable tool for evaluation. Granted, the sensitivity is low because not many men with low PSA have cancer. 264
Vol. 162,264-284, July 1% Printed in U.S&
TERJOUBNM. OF U ~ L O G Y Copyright 8 1999 by AMERICAN UR0uw;lclu.AssocunoN, hc.
ABSTRACTS BENIGN A N D MALIGNANT NEOPLASMS OF PROSTATE American College of Preventive Medicine Practice Policy. Screening for Prostate Cancer in American Men
R. FERRINIAND S. H. Woou, American College of Preventive Medicine, Washington, D. C. h e r . J. Rev. Med.,15: 81-84, 1998 Based on a review of the current literature and recommendations, the American College of Preventive Medicine presents a practice policy statement on screening for prostate cancer in American men.
Editorial Comment: With time there has been a gradual decline in opposition to prostate cancer screening. For example, these authors admit that prostate cancer is a significant and growing cause of morbidity and is not amenable to primary prevention. Although they do not recommend routine population screening, they state that men 50 years old or older with a life expectancy of greater than 10 years should be given information about the potential benefits and harm of, and be allowed to make their o w n choice about screening. Patrick C. Walsh, M.D. Evaluation of the Digital Rectal Examination as a Screening Test for Prostate Cancer F. H. SCHRODER, P. VAN DER MAAS,P. BEEMSTERBOER, A. B. KRUGER, R. HOEDEMAEKER, J. RIETBERGEN AND R. KRANSE ON BEHALF OF THE ROTTERDAM SECTION OF THE EUROPEAN RANDOMIZED STUDY OF SCREENING FOR PROSTATE CANCER, Department of Urology, Academic Hospital, and Institutes of Public Health and Pathology, Erasmus University, Rotterdam, The Netherlands J. Natl. Cancer Inst., 9 0 1817-1823, 1998 Background: The utility of digital rectal examination (DRE) as a screening test for early detection of prostate cancer has not been established. Therefore, we evaluated the usefulness of DRE as a stand-alone screening test and in conjunction with measured serum prostate-specific antigen (PSA) levels of 0 -3.9 ng/mL and transrectal ultrasonography (TRUS). Methods: Our study population consisted of 10,523 men aged 54-76 years who were randomly assigned to the screening arm of the Rotterdam, The Netherlands, section of the European Randomized Study of Screening for Prostate Cancer. The underlying prevalence of detectable prostate cancer was estimated by logistic regression analysis and used for calculating the sensitivity of DRE as a test. Pathologic characteristics of 105 radical prostatectomy specimens were used to determine the aggressiveness of the tumors diagnosed (and missed) by DRE. Results: The overall detection rate for prostate cancer in this population when serum PSA measurement, DRE, and TRUS were used was 4.59'0, and the detection rate with DRE alone was 2.5%. The positive predictive value of DRE ranged from 4% to 11% in men with PSA levels of 0-2.9 ng/mL and from 33% to 83% in men with PSA levels of 3.0-9.9 ng/mL or more. Most tumors detected by DRE in men with PSA levels of less than 4.0 ng/mL were small (mean volumes = 0.24-0.83 mL), and most were well differentiated (Gleason scores of 6 or less). Minimal, moderate, and advanced cancers were seen in 42%, 42%, and 16% of men, respectively, with a PSA level of 4.0 n g / d or less. DRE alone allowed detection of 264 (55.8%) of 473 cancers; 82 (17.3%) of the 473 cancers would have remained undetected by PSA-based screening alone (i.e., no follow-up procedures for PSA values of 0-3.9 ng/mL). Conclusions: For PSAvalues of 0-3.9 ng/mL, the positive predictive value and sensitivity of DRE, tumor volume, and tumor grade were strongly dependent on PSA level. DRE has a poor performance in low PSA ranges. Editorial Comment: This article is well done. However, the conclusions of the authors puzzle me. In patients with prostate specific antigen (PSA) less than 4 ngJml. the specificity of digital rectal examination for these trained observers was 90%, which is the highest ever reported. Also, the positive predictive values were identical to the recent study from Washington University in which those authors concluded "the positive predictive value of suspicious digital rectal examination was appreciable in men with low serum PSA. The majority of cancers detected by digital rectal examination had features of clinically important and potentially incurable disease."' Schroder et al state that many of the cancers detected in men with PSA less than 4 ngJml. did not show characteristics of aggressive tumor. However, when one looks at the data, in men with PSA 0 to 1the average tumor volume was greater than 0.2 cc and in those with PSA 2 to 2.9 and 3 to 3.9 Gleason scores were 7. I would reverse the conclusions of the authors and state that in men with low PSA digital rectal examination has a high specificity and is a valuable tool for evaluation. Granted, the sensitivity is low because not many men with low PSA have cancer. 264