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INTRODUCTION

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When planning a screening programme for any disease, five key questions should be addressed [1]. Is the test screening for a significant, serious disease? Are the tests used to screen for the condition accurate? Is the outcome of the disease changed or improved by the use of the screening test? Does screening cause the patient harm? Does the screening produce more good than harm? This chapter will review each of these questions in an attempt to address the appropriateness of prostate cancer screening in contemporary medical practice.

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IS THE TEST SCREENING FOR A SIGNIFICANT, SERIOUS DISEASE?

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After lung cancer, prostate cancer is the second leading cause of cancer death in men in both the USA and Canada [2]. By the age of 79, men have a 1 in 8 chance of being diagnosed with prostate cancer, but a much lower chance of dying from the disease. African-American men are at a particularly high risk of developing prostate cancer. Between 1998 and 2002 the estimated prostate cancer incidence among African-American men was 272 per 100 000 men, one of the highest rates in the world [2, 3].

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In the USA, prostate cancer incidence rates rose steadily from 1969 through the 1980s and then much more rapidly during the late 1980s and early 1990s, peaking in 1992 (Figure 4.1). Epidemiologists attribute the widespread use of transurethral resection of the prostate during the 1970s and 80s and the subsequent rise in testing for prostate-specific antigen (PSA) as the primary explanation for these trends [4]. Since 1992, US prostate cancer incidence rates have fallen by more than 11%, but now appear to be rising again. Contemporary incidence rates are considerably higher than previously recorded during the 1970s. From 1998 through to 2002, the US prostate cancer incidence rate was estimated to be 164 per 100000 men, age-adjusted to the 2000 US standard population [3].

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Figure 4.1

Incidence of prostate cancer in the USA 1975–2001 [5].

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In the USA, mortality from prostate cancer has risen slowly for many decades, peaking in 1998 at a rate of 42 per 100 000 men, age adjusted to the 2000 US standard population [2] (Figure 4.2). Since then mortality rates have fallen by more than 25%. In 2006, the prostate cancer mortality rate was estimated to be 30.3 per 100 000 men, age adjusted to the 2000 US standard population [3]. When death rates are age-adjusted to the World Health Organization world standard population, the rates of prostate cancer seen in the USA are similar to rates seen in countries such as France, Germany and the UK, and somewhat lower than rates seen in Scandinavia. In contrast, the mortality rates from prostate ...

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