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Gann, Charles H. Hennekens, Meir J. Stampfer, “A prospective evaluation of plasma prostate-specific antigen for detection of prostatic cancer,” JAMA 273 (1995), pp. 289–294; Gerrit Draisma et al., “Lead time and overdiagnosis in prostate-specific antigen screening: Importance of methods and context,” Journal of the National Cancer Institute (JNCI) 101 (2009), pp. 274–383; Ruth Etzioni et al., “Overdiagnosis due to prostate-specific antigen screening : Lessons from U.S. prostate cancer incidence trends,” JNCI 94 (2002), pp. 981–990; Peter R. Carroll et al., “Serum prostate-specific antigen for the early detection of prostate cancer: Always, never, or only sometimes?” Journal of Clinical Oncolog y (JCO) 29 (2011), pp. 345–347; E. David Crawford et al., “Comorbidity and mortality results from a randomized prostate cancer screening trial,” JCO 29 (2011), pp. 355–361; Stacy Loeb et al., “What is the true number needed to screen and treat to save a life with prostate-specific antigen testing?” JCO 29 (2011), pp. 464–467.

Recent studies question the current use of changes in PSA levels to predict prostate cancer; see Andrew J. Vickers et al., “An empirical evaluation of guidelines on prostate-specific antigen velocity in prostate cancer detection,” JNCI 103 (2011), pp. 1–8; Nicholas Bakalar, “Prostate guideline causes many needless biopsies, study says,” New York Times, February 27, 2011.

Despite these vexing issues, the death rate from prostate cancer has gradually but consistently declined since the advent of PSA screening. For example, data from Olmsted County in Minnesota, the location of the Mayo Clinic, show that age-adjusted mortality rates from prostate cancer declined 22 percent compared with the rate measured in the years before PSA testing : Manish Kohli, Donald J. Tindall, “New developments in the medical management of prostate cancer,” Mayo Clinic Proceedings 85 (2010), pp. 77–86.

Given the controversy over the value of screening, it is not surprising that specialty organizations published different recommendations regarding PSA testing. The American Cancer Society (ACS) emphasized the need for involving men in the decision of whether to screen or not. For men who decided to be screened, the ACS recommended PSA testing for average-risk men beginning at fifty years of age. Those at higher risk, like African American men or those with a brother or father with prostate cancer diagnosed before the age of sixty-five, should begin a screening discussion at ages forty to forty-five: Andrew M. D. Wolf et al., “American Cancer Society Guideline for the early detection of prostate cancer: Update 2010,” Cancer 60 (2010), pp. 70–98. The American Urological Association also endorsed shared decision making about risks and benefits but recommended annual screening beginning at the age forty: Kirsten L. Greene et al., “Prostate specific antigen best practice statement: 2009 update,” Journal of Urology 182 (2009), pp. 2232–2241. The United States Preventive Services Task Force, which advises the government, concluded in 2008 that there was insufficient evidence to assess the balance of benefits and harms of prostate cancer screening in men younger than seventy-five: U.S. Preventive Services Task Force, “Screening for prostate cancer: U.S. Preventive Services Task Force Recommendation Statement,” Ann Intern Med 149 (2008), pp. 185–191. The Canadian Task Force on Preventive Health Care recommended against screening for prostate cancer with PSA: J. W. Feightner, “Recommendations on secondary prevention of prostate cancer from the Canadian Task Force on the Periodic Health Examination,” Canadian Journal of Oncology 4 (Suppl. 1) (1994), pp. 80–81. The American College of Physicians, an organization of internists, recommended individualizing the decision to screen after a thorough discussion with the patient: Kenneth Lin et al., “Benefits and harms of prostate-specific antigen screening for prostate cancer: An evidence update for the U.S. Preventive Services Task Force,” Ann Intern Med 149 (2008), pp. 192–199.

Given this complexity,