I believe people ARE trying to do exactly what you describe, but there is still major disagreement over how to classify AS patients into risk subgroups (and for good reason) and — as you point out — in general there is consensus that patients should be making the decisions about how to get treated. I would NOT be in favor of any national guideline that said (for example) “Every man with a PSA > 3.0 and a Gleason grade of 6 or less who is > 65 years of age should receive active surveillance” (although I might well consider such guidance to be generally wise).

What we are facing here is the problem of the (generally) slow progression of prostate cancer, which can all too commonly result in the fact that by the time we have enough data to resolve a specific problem, we have (in fact) already moved beyond that problem to the next because of technology. All the active surveillance trials are going to take at least a decade or more to demonstrate anything really meaningful. We ought to be able to develop a better test within that 10-year timeframe if we really focused on it.

Sure we need a better marker. That said, why not control the claimed rate of over-diagnosis and over-treatment by a more sensible application of existing protocols?

While AS protocols are not widely accepted yet by urology they could go a long way. Same with treating older men with existing comorbidities. I say this with some reluctance because I ultimately believe that patients should be the ones making the decision if properly informed of the risks and benefits.

I don’t think anyone is arguing over the fact that there is a significant reduction in the mortality rate in the USA. I think the issue is about the cost of that reduction in financial terms (“over-diagnosis”) and in clinical terms (“over-treatment”). What we really do NOT know is who NEEDS a PSA test and when. Because of that, we end up proposing that “everyone” should get a PSA test on a regular basis (“screening”). As you know, even I am far from convinced that that is a good idea. We need a better test!

:O)

It is difficult to get actual data about the rate of use of PSA anywhere. I have in the past read that there is less than 10% of asymptomatic men tested in the EU. Nordic countries have a high mortality rate and relative low incidence, These are signs that PSA is not used frequently to diagnose PCa.

Here, the “widespread” use is low in men 50 or under, and as high as 55% in older men. In spite of this we have managed a 40% reduction in the mortality rate. When, if ever, will this reduction be considered significant?

I think that “Something is rotten in the state of Sweden” when one considers these data.

Swedes are not stupid. The PSA test was developed there! Just because the government does not endorse mass, population-based screening doesn’t mean that men aren’t getting tested. Indeed, given the considerable number of publications that come out of Sweden on this subject, it is clear that they are. So I don’t know what to make of what seems to be bizarre data (although of course a paper on screening published in 2004 could be based on data going back who knows how long).

One also needs to take account of the facts that: (a) On a global basis, Sweden has always had a very high suicide rate. (It’s the long winter nights and all those pickled herrings that does it.) (b) For a European country, the relative incidence and mortality from prostate cancer has always been high in Sweden (although no one seems to have a particularly clear idea of why).

Objective: To estimate the lifetime cost per detected potentially curable cancer and the economic impact on healthcare of repeated screening for prostate cancer in Sweden in a cohort of men aged 50–69 years.

Material and Methods: All 9171 men in a geographically defined population were included: 1492 were randomized to screening in four rounds every third year and 7679 constituted a control group. Digital rectal examination and prostate-specific antigen screening in different combinations were used as diagnostic measures. Costs associated with administration of the screening programme, loss of patient time, diagnostic measures and management strategies were included. A decision model was developed to calculate the total cost of the programme.

Results: The incremental cost per extra detected localized cancer was 168000 SEK and per potentially curable cancer 356000 SEK. Introducing this screening programme for prostate cancer in Sweden would incur 244 million SEK annually in additional costs for screening and treatment compared to a non-screening strategy.

Conclusion: There is still no scientific evidence that patients will benefit from screening programmes. Prostate cancer screening would probably be perceived as cost-effective if potentially curable patients gained on average at least 1 year of survival.

No small wonder men in Sweden feel that way!

According to the WHO database: the PCa mortality rate in 1987 was 44.1 per 100K population and it 2005 it has increased to 54.8 per 100K population.

The utilization of PSA in Sweden has to be very low. If the overdiagnosis figure here is as high as they claim, men not destined to die of PCa need not to worry when diagnosed. Makes sense, no?