To the Editor.\p=m-\TheEditorial by Oesterling1 recommended screening all men over the age of 55 years for early prostate
with annual DRE and PSA levels. This recommendation violates one of the basic principles for deciding to screen for a medical condition during periodic health examinations. In order for a screening procedure to be beneficial, there must be evidence that treating the disease earlier results in decreased morbidity. In the Editorial, Oesterling admits that there is no conclusive evidence that early treatment with radical prostatectomy or radiation therapy is beneficial for all patients with early prostate cancer. Consequently, recommending mass screening for early prostate cancer at this time is, at best, premature. In light of the great variability in the natural history of untreated early prostate cancer reported by Johansson et al,2 it seems more prudent to await proof that treating early prostate cancer does improve morbidity and/or mortality before embarking on a multimillion-dollar screening program. cancer
Rita T. Layson, MD Moses H. Cone Memorial Greensboro, NC
Hospital
1. Oesterling JE. Prostate-specific antigen: improving its ability to diagnose early prostate cancer. JAMA. 1992;267:2236-2238. 2. Johansson J-E, Adami H-O, Andersson S-E, Bergstr\l=o"\mR, Holmberg L, Krusemo UB. High 10-year survival rate in patients with early, untreated prostatic cancer.
JAMA. 1992;267:2191-2196.
we're at it, why are all my patients asking for it, and why are the news media, television physicians, and even congressmen jumping on the PSA bandwagon? Perhaps they're bored with the cholesterol bandwagon. Thomas E.
Amesbury, 1.
better than that for serum PSA concentration." He then contradicts himself with the statement, "Thus, the serum PSA level going from 1.8 \g=m\g/Lto 2.9 \g=m\g/Lin 1 year's time would be significant and may lead to the detection of potentially curable prostate cancer, even though the values are well within the reference range." In the first statement, he acknowledges that such a change in the PSA level is no better (in fact, worse—11% sensitivity for changes below the level of 4 µg/L) at detecting prostate cancer than the absolute PSA value would be. He seems to be muddling the concept of specificity with that of sensitivity, because the sentence he writes directly between the above two is, "Nevertheless, the increased specificity will undoubtedly have valuable impli¬ cations as more and more patients return annually for a serum PSA determination and DRE." He seems to be more enthusiastic for PSA testing than is merited. He gives short shrift to the study by Johansson et al:ì in the same issue, which showed a high survival rate for prostate cancer patients who received no initial treatment. At the same time, he exaggerates the value of the findings of Carter et al and ignores their stipulation, "The questions of who may benefit from serial measurements of PSA, at what age, and at what intervals will require further study." Thus far, PSA screening for presumably normal men is not recommended by the US Preventive Services Task Force,4 the Canadian Task Force on the Periodic Health Examina¬ tion,'1 the American Cancer Society,6 or the National Cancer Institute.7 So why is Oesterling expecting "more and more patients (to) return annually for a serum PSA..."? And while
MD
Mass
Oesterling JE. Prostate-specific antigen: improving its ability to diagnose early
JAMA. 1992;267:2236-2238. HB, Pearson JD, Metter EJ, et al. Longitudinal evaluation of prostate\x=req-\ specific antigen levels in men with and without prostate disease. JAMA. 1992;267:
prostate
cancer.
2. Carter
2215-2220. 3. Johansson J-E, Adami H-O, Andersson S-E, Bergstr\l=o"\mR, Holmberg L, Krusemo UB. High 10-year survival rate in patients with early, untreated prostatic cancer.
JAMA. 1992;267:2191-2196. 4. US Preventive Services Task Force. Screening for prostate cancer. In: Guide to Clinical Preventive Services. Baltimore, Md: Williams & Wilkins; 1989:63-66. 5. Canadian Task Force on the Periodic Health Examination. The periodic health examination. Can Med Assoc J. 1979;121:1194-1254. 6. American Cancer Society. Guidelines for the cancer-related check-up: recommendations and rationale. CA. 1980;30:34. 7. National Cancer Institute. Working Guidelines for Early Cancer Detection: Rationale and Supporting Evidence to Decrease Mortality. Bethesda, Md: National Cancer Institute; 1987.
To the Editor.\p=m-\Wewould like to comment
on
the Editorial
by Oesterling1 regarding PSA testing. Oesterling, in recommending PSA testing and surgery, appears to assume that all prostate cancers discovered by PSA testing will act in a malignant fashion and require surgery. This assumption needs to be
clinician, I get confused enough already by statistical terms such as specificity, sensitivity, false-positive, and true-negative. I don't need to be made more confused by those who write the editorials, such as Oesterling in his JAMA Editorial on PSA testing.1 The study by Carter et al2 in the same issue demonstrated an improved specificity, but unimproved or worsened sensitivity of the PSA test for detecting prostate cancer, by using its rate of change per year rather than its absolute value. Oesterling, in referring to that study, states, "The sensitivity for the rate of change (of PSA) was not significantly To the Editor.\p=m-\Asa nonresearcher
Lindow,
addressed.
First, autopsy studies have demonstrated that
many or of prostatic carcinoma are latent or indolent. The incidence of prostate cancer increases from 30% in the fifth decade to close to 100% in men over the age of 90 years. In contrast to this increasing incidence, the cumulative lifetime risk for death is only 2.5%,2 and the average 5-year age\x=req-\ specific prostate cancer mortality in men aged 50 through 74 years never exceeds 0.14%.3 There are currently no data to show that PSA testing differentiates between indolent and aggressive cancers. Screening for cancer of the prostate will likely find clinically inactive prostate cancer more often than cancer that is likely to progress and cause symptoms or death. Johansson et al4 have shown that the corrected 10-year sur¬ vival for initially untreated grade 1 tumors is unlikely to be lower than 84.2%. Second, the Editorial makes no mention of the significant morbidity and mortality from radical prostatectomy: 1% to 2% risk of mortality for radical prostatectomy, 25% risk of impotence, 18% risk of urinary stricture, 6% risk of inconti¬ nence, and 3% risk of rectal injury.5 Thus, what is deemed prudent in the Editorial, ie, yearly PSA testing for men 55 years of age and older, may be more likely to identify patients without clinically important disease than those with aggressive cancers. The health benefits (eg, decreased morbidity and mortality) of screening for prostatic carcinoma with yearly PSA testing and ultrasonography have not been shown to exceed the negative consequences. Subjecting the entire male population over 55 years of age to expensive prostate cancer screening programs in order possibly to benefit the few men with clinically aggressive prostatic carcinoma is not the most prudent course of action. Such a course will result in poorer health outcomes for the population, and would cost approximately $27.9 billion if all men in the United States between the ages of 50 and 70 years were screened by PSA and subsequently treated.5 It is time for us to broaden our perspective to include the morbidity and mortality from unproven treatments such as radical prostatectomy and to focus on what is most prudent for the entire population at risk. Before implementing a screen¬ ing program for prostate cancer, two issues need to be remost
cases
Downloaded From: http://jama.jamanetwork.com/ by a New York University User on 05/30/2015
with annual DRE and PSA levels. This recommendation violates one of the basic principles for deciding to screen for a medical condition during periodic health examinations. In order for a screening procedure to be beneficial, there must be evidence that treating the disease earlier results in decreased morbidity. In the Editorial, Oesterling admits that there is no conclusive evidence that early treatment with radical prostatectomy or radiation therapy is beneficial for all patients with early prostate cancer. Consequently, recommending mass screening for early prostate cancer at this time is, at best, premature. In light of the great variability in the natural history of untreated early prostate cancer reported by Johansson et al,2 it seems more prudent to await proof that treating early prostate cancer does improve morbidity and/or mortality before embarking on a multimillion-dollar screening program. cancer
Rita T. Layson, MD Moses H. Cone Memorial Greensboro, NC
Hospital
1. Oesterling JE. Prostate-specific antigen: improving its ability to diagnose early prostate cancer. JAMA. 1992;267:2236-2238. 2. Johansson J-E, Adami H-O, Andersson S-E, Bergstr\l=o"\mR, Holmberg L, Krusemo UB. High 10-year survival rate in patients with early, untreated prostatic cancer.
JAMA. 1992;267:2191-2196.
we're at it, why are all my patients asking for it, and why are the news media, television physicians, and even congressmen jumping on the PSA bandwagon? Perhaps they're bored with the cholesterol bandwagon. Thomas E.
Amesbury, 1.
better than that for serum PSA concentration." He then contradicts himself with the statement, "Thus, the serum PSA level going from 1.8 \g=m\g/Lto 2.9 \g=m\g/Lin 1 year's time would be significant and may lead to the detection of potentially curable prostate cancer, even though the values are well within the reference range." In the first statement, he acknowledges that such a change in the PSA level is no better (in fact, worse—11% sensitivity for changes below the level of 4 µg/L) at detecting prostate cancer than the absolute PSA value would be. He seems to be muddling the concept of specificity with that of sensitivity, because the sentence he writes directly between the above two is, "Nevertheless, the increased specificity will undoubtedly have valuable impli¬ cations as more and more patients return annually for a serum PSA determination and DRE." He seems to be more enthusiastic for PSA testing than is merited. He gives short shrift to the study by Johansson et al:ì in the same issue, which showed a high survival rate for prostate cancer patients who received no initial treatment. At the same time, he exaggerates the value of the findings of Carter et al and ignores their stipulation, "The questions of who may benefit from serial measurements of PSA, at what age, and at what intervals will require further study." Thus far, PSA screening for presumably normal men is not recommended by the US Preventive Services Task Force,4 the Canadian Task Force on the Periodic Health Examina¬ tion,'1 the American Cancer Society,6 or the National Cancer Institute.7 So why is Oesterling expecting "more and more patients (to) return annually for a serum PSA..."? And while
MD
Mass
Oesterling JE. Prostate-specific antigen: improving its ability to diagnose early
JAMA. 1992;267:2236-2238. HB, Pearson JD, Metter EJ, et al. Longitudinal evaluation of prostate\x=req-\ specific antigen levels in men with and without prostate disease. JAMA. 1992;267:
prostate
cancer.
2. Carter
2215-2220. 3. Johansson J-E, Adami H-O, Andersson S-E, Bergstr\l=o"\mR, Holmberg L, Krusemo UB. High 10-year survival rate in patients with early, untreated prostatic cancer.
JAMA. 1992;267:2191-2196. 4. US Preventive Services Task Force. Screening for prostate cancer. In: Guide to Clinical Preventive Services. Baltimore, Md: Williams & Wilkins; 1989:63-66. 5. Canadian Task Force on the Periodic Health Examination. The periodic health examination. Can Med Assoc J. 1979;121:1194-1254. 6. American Cancer Society. Guidelines for the cancer-related check-up: recommendations and rationale. CA. 1980;30:34. 7. National Cancer Institute. Working Guidelines for Early Cancer Detection: Rationale and Supporting Evidence to Decrease Mortality. Bethesda, Md: National Cancer Institute; 1987.
To the Editor.\p=m-\Wewould like to comment
on
the Editorial
by Oesterling1 regarding PSA testing. Oesterling, in recommending PSA testing and surgery, appears to assume that all prostate cancers discovered by PSA testing will act in a malignant fashion and require surgery. This assumption needs to be
clinician, I get confused enough already by statistical terms such as specificity, sensitivity, false-positive, and true-negative. I don't need to be made more confused by those who write the editorials, such as Oesterling in his JAMA Editorial on PSA testing.1 The study by Carter et al2 in the same issue demonstrated an improved specificity, but unimproved or worsened sensitivity of the PSA test for detecting prostate cancer, by using its rate of change per year rather than its absolute value. Oesterling, in referring to that study, states, "The sensitivity for the rate of change (of PSA) was not significantly To the Editor.\p=m-\Asa nonresearcher
Lindow,
addressed.
First, autopsy studies have demonstrated that
many or of prostatic carcinoma are latent or indolent. The incidence of prostate cancer increases from 30% in the fifth decade to close to 100% in men over the age of 90 years. In contrast to this increasing incidence, the cumulative lifetime risk for death is only 2.5%,2 and the average 5-year age\x=req-\ specific prostate cancer mortality in men aged 50 through 74 years never exceeds 0.14%.3 There are currently no data to show that PSA testing differentiates between indolent and aggressive cancers. Screening for cancer of the prostate will likely find clinically inactive prostate cancer more often than cancer that is likely to progress and cause symptoms or death. Johansson et al4 have shown that the corrected 10-year sur¬ vival for initially untreated grade 1 tumors is unlikely to be lower than 84.2%. Second, the Editorial makes no mention of the significant morbidity and mortality from radical prostatectomy: 1% to 2% risk of mortality for radical prostatectomy, 25% risk of impotence, 18% risk of urinary stricture, 6% risk of inconti¬ nence, and 3% risk of rectal injury.5 Thus, what is deemed prudent in the Editorial, ie, yearly PSA testing for men 55 years of age and older, may be more likely to identify patients without clinically important disease than those with aggressive cancers. The health benefits (eg, decreased morbidity and mortality) of screening for prostatic carcinoma with yearly PSA testing and ultrasonography have not been shown to exceed the negative consequences. Subjecting the entire male population over 55 years of age to expensive prostate cancer screening programs in order possibly to benefit the few men with clinically aggressive prostatic carcinoma is not the most prudent course of action. Such a course will result in poorer health outcomes for the population, and would cost approximately $27.9 billion if all men in the United States between the ages of 50 and 70 years were screened by PSA and subsequently treated.5 It is time for us to broaden our perspective to include the morbidity and mortality from unproven treatments such as radical prostatectomy and to focus on what is most prudent for the entire population at risk. Before implementing a screen¬ ing program for prostate cancer, two issues need to be remost
cases
Downloaded From: http://jama.jamanetwork.com/ by a New York University User on 05/30/2015
