Too much mammography
BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g1403 (Published 11 February 2014) Cite this as: BMJ 2014;348:g1403All rapid responses
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Prostate cancer screening
A recent editorial in the BMJ (BMJ| 15 FEBUARY 2014 |VOLUME 348 ) reminds readers that prostate cancer screening by PSA testing is not encouraged in the United Kingdom and other countries. But is this the right advice ?
PSA testing is very helpful in diagnosing prostate cancer, but is not by itself diagnostic. The higher the PSA level, the more likely the diagnosis of prostate cancer, and the poorer the histological grading.(1)
PSA testing will detect prostate cancer at an earlier stage, and reduce the likelihood of late presentation.(2 ) Active surveillance relies on PSA testing. Following treatment for prostate cancer, cancer recurrence is also monitored by PSA testing - a rise in levels indicating re-activation of disease.
The best studies on prostate cancer screening, with PSA, come from European studies ( 3,4 ), and the findings reveal a significant reduction in prostate cancer mortality with PSA screening.
PSA screening detects a lot of low risk cancers - cancer that may not cause any health problems in a man's lifetime. The cost of screening, unnecessary intervention, and the associated procedural complications need to be addressed.
Well-differentiated disease carries a much better prognosis than poorly differentiated disease.(5 )
Active surveillance is now a preferred option for men with low risk disease. Only men with Gleeson scores of 7 or above should be considered for treatment. However, a recent 20 year study on men with intermediate disease found a significant reduction in prostate cancer mortality (11%) in those treated with Radical Prostatectomy, as compared with watchful waiting.(6) This latest study provides useful advice in counselling men with intermediate disease.
I believe there should be more PSA testing, not less. If only there were such a test available to detect Ovarian cancer. I cannot see how the current screening guidelines will help reduce the death rate from prostate cancer.
References.
1. Guimaraes MS,Quintal MM, Meirelles LR, et al. Gleeson score as a predictor of clinicopathologic findings and biochemical( PSA ) progression, following radical prostatectomy. Int.Braz.J.Urol. 2008;34:23-29
2. Wolters T, Roobol MJ, Steyerberg EW, et al. The effect of study arm on prostate cancer treatment in the large screening trial ERSPC. Int. J. Cancer, 2010;126: 2387- 2393
3. Schroder FH, Hugosson J, Roobol MJ, et al. Screening and prostate cancer mortality in a randomized European study. N. Engl. J.Med. 2009;360:1320-1328
4. Hugosson J, Carlsson S, Aug G, et al. Mortality results from the Goteborg randomized population-based prostate cancer screening trial. Lancet Oncol. 2010;11:725-732
5. Albertson PC, Hanley JA, Fine J. 20 year outcomes following conservative management of clinically localized prostate cancer. JAMA 2005;293:2095- 2101
6. Bill- Axelson A, Holmberg L, Garmo H, et al. Radical Prostatectomy or Watchful Waiting in Early Prostate Cancer. N Engl J Med. 2014;370:932- 942
Competing interests: No competing interests
We would like to highlight another crucial point against the backdrop of the on-going discussion about population-based breast cancer screening programme: what is the proportion of women that makes an informed choice for (or against) participation?
In Germany, breast cancer screening is offered as a population-based programme to which women aged 50 to 69 are invited biannually with a specified appointment. This practice goes on despite unanswered questions and lack of empirical evidence about benefits and harms of population-based breast cancer screenings. Women receive a leaflet informing them about harms and benefits, but as a consequence of the official character of the invitation process (which is based on population registry data) women may feel pushed to participate. Furthermore, many health insurances reward mammography screening uptake through bonus-programmes. These pushing factors counteract efforts to give women the opportunity to make an informed choice for or against participation in the programme based on best available evidence.
Preliminary and not yet published results from our ongoing cross-sectional study (InEMa-study) at Bielefeld University, Germany, show that more than two-thirds of women invited for the first time to the population based mammography screening in the study region do not make an informed choice. The results show that women overestimate the benefits (e.g. lives saved by screening), whereas harms (e.g. overdiagnosis) are largely unknown. In a qualitative pre-study, we found that the concept of better-being-safe-than-sorry was often used as rationale for screening decisions. Increasing the proportion of women that make an informed choice about mammography screening is therefore imperative for the further development of breast cancer screening, with or without population-based programmes.
Competing interests: No competing interests
Re: Too much mammography
Official Eurostat data from Greece show that in Greek women breast cancer incidence and mortality rates are less than those in many other European Countries. [1][2]
Eurostat data also informs us that only 5% of Greek women participate in national or charity mammography screening programs, and only 5% of breast cancers are detected at early stages. [3][4]
Availability of modern potent chemotherapeutic agents or technologically advanced radiotherapies in Greek hospitals is low.
Despite widespread refusal for regular clinical breast examinations and rejection of preventive screening mammograms, breast cancer mortality rates did not rise in Greek women, in the past decades studied, compared to other European Countries where participation in mammography screening programs and resulting detection of early stage cancers is much higher.
Such findings make us realize that the attributed value of such screening programs is questionable.
References
[1] http://ec.europa.eu/eurostat/statistics-explained/index.php/File:Causes_...
[2] http://eu-cancer.iarc.fr/eucan/CancerOne.aspx?Cancer=46&Gender=2
[3] http://www.research.ed.ac.uk/portal/files/11336104/Mammography_screening...
[4] http://ec.europa.eu/eurostat/statistics-explained/index.php/File:EHIS_F4...(all_women_aged_15_years_and_over)_Figure_4.png
Competing interests: No competing interests