Screening vs. clinical detection: prostate cancer in China


A newly published study has compared the clinical and pathological characteristics of screen-detected and clinically diagnosed prostate cancers in Chinese men. Hua et al. report data from a two-part study carried out in Nanjing.

In the first part of this study, they collected data on 82 men who had clinically diagnosed prostate cancer but who had never had any form of prior test for prostate cancer risk. They then compared the data from these men with clinically detected disease to the data from 8,562 men aged ≥ 50 years who were screened for prostate cancer using PSA testing 0ver an 18-month period between July 2004 and December 2005. In the screening portion of the study, participants with a serum PSA ≥ 4.0 ng/ml were recommended for transrectal ultrasonography (TRUS)-guided prostate needle biopsy. (The abstract of the paper does not provide any details about numbers of biopsy cores.)

Comparison of the clinical and pathological features of the screened versus clinically diagnosed cancers showed the following:

  • 719/8,562 of the screened men (8.4 percent) had PSA levels ≥ 4.0 ng/ml.
  • Biopsies were actually carried out on only 295/719 men with a PSA  ≥ 4.0 ng/ml, and 58 prostate cancers were detected.
  • The biopsy rate, positive predictive value (PPV), and detection rate were 41.0, 19.7, and 0.68 percent among the screened population, respectively.
  • Patients with prostate cancer but with PSA levels < 20 ng/ml  were significantly more common among the screened group (55.2 percent) than among the clinically detected group (22.4 percent).
  • The same was true for patients with Gleason scores < 7 (60.3 vs. 34.1 percent), organ-confined tumors (87.9 vs. 26.8 percent), and opportunities for radical prostatectomy (50.0 vs. 18.3 percent).

Now there are clearly “problems” with this study. For example, only 41 percent of the men who had an elevated PSA test actually went on to have a biopsy, so we have no idea what the rate of prostate cancer was in these 424 men. On the other hand, this study clearly confirms what has been known for some years in non-Chinese populations — that PSA screening is effective for early detection of prostate cancer in men ≥ 50 years of age, and that such screening is associated with lower PSA levels, fewer Gleason scores of 7-10, earlier clinical stage, and greater chances for curative treatment. In other words, screening can “stage-shift” prostate cancer in China from an advanced stage at diagnosis to stage with a high chance for curative therapy, just as it has in other parts of the world.

Of course, if prostate cancer screening becomes commonplace in China, the world’s most populous nation will also have to face up to the question of the most appropriate way to manage men with early-stage, screen-detected prostate cancer.

3 Responses

  1. Just to complete this sentence can I suggest adding a few words (the ones in italic):

    “… PSA screening is effective for early detection of prostate cancer in men ≥ 50 years of age, and that such screening is associated with lower PSA levels, fewer Gleason scores of 7-10, earlier clinical stage, and greater chances for curative treatment” and of unnecessary invasive treatment that will affect the quality of life of the men diagnosed and their families for decades.

    I wondered, when I read this brief (but informative) commentary, if the majority of men with an elevated PSA, who did not have biopsy, went back to traditional “Chinese” medicine rather than “Western” medicine?

  2. The only way to detect PCa is through a positive biopsy. To say that the detection rate of the screened population was 0.68% is misleading when only 41% of those with an abnormal PSA were actually biopsied. The “real” detection rate was almost 20%.

    In China, like here in America, screening with PSA provides choice. To negate that value is to condemn men to a higher risk of being diagnosed with advanced disease and a higher risk of disease-specific death.

    The noted stage-shift at diagnosis is a demonstration that prostate cancer can progress to more advanced stages and given enough time to become lethal and in doing so to cause significant damage to the QOL of those men.

  3. I wouldn’t believe anything the Chinese say. They have been caught falsifying data for years.

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