University of Toronto, Sunnybrook Health Sciences Centre, 2075 Bayview Ave MG 408, Toronto, Ontario, Canada.
Curr Opin Endocrinol Diabetes Obes. 2013 Jun;20(3):204-9. doi: 10.1097/MED.0b013e328360332a.
To summarize the evidence, now extensive, that efforts to reduce prostate cancer mortality by screening and early detection result in overdiagnosis of disease that is clinically insignificant, and would never have been diagnosed in the patient's lifetime in the absence of screening. Overdiagnosis may result in overtreatment, which in the case of prostate cancer often carries significant, long-term quality-of-life effects. The review also addresses the solutions to the problem of overdiagnosis and overtreatment, and summarizes the outcomes of these approaches.
Screening for prostate cancer has been demonstrated to reduce mortality, although with a high number needed to treat. One approach to this problem is to offer patients with favorable risk disease an initial conservative approach, with close monitoring and treatment for those patients who are reclassified as higher risk over time. Much preclinical data indicates that Gleason 6 prostate cancer does not carry the hallmarks of malignancy. However, a number of recent studies have demonstrated that in patients diagnosed with favorable risk prostate cancer (Gleason 6 or less, prostate-specific antigen <10), about 30% will harbor higher grade cancer and benefit from treatment. These patients are identifiable by a combination of repeat biopsy, serial prostate-specific antigen, and in borderline cases, multiparametric MRI.
Active surveillance is a powerful solution to the problem of overdiagnosis and overtreatment associated with screening for prostate cancer. For the 40-50% of patients with favorable risk prostate cancer, it offers the benefit of personalized medicine, avoiding treatment and related quality-of-life effects altogether in the majority, and providing definitive management for the minority who are reclassified with higher risk disease over time.
目的综述：总结目前大量的证据，这些证据表明，通过筛查和早期检测来降低前列腺癌死亡率的努力导致了疾病的过度诊断，而在没有筛查的情况下，这些疾病在患者的有生之年临床上是微不足道的，而且永远不会被诊断出来。过度诊断可能导致过度治疗，而在前列腺癌的情况下，这种治疗通常会带来显著的长期生活质量影响。该综述还探讨了解决过度诊断和过度治疗问题的方法，并总结了这些方法的结果。
最近的发现：已经证明，筛查前列腺癌可以降低死亡率，尽管需要治疗的人数很多。解决这个问题的一种方法是为患有低危疾病的患者提供初始保守治疗方案，并对那些随着时间的推移被重新分类为高危的患者进行密切监测和治疗。大量的临床前数据表明，Gleason 6 前列腺癌没有恶性肿瘤的特征。然而，最近的一些研究表明，在被诊断为低危前列腺癌（Gleason 评分 6 或更低，前列腺特异性抗原 <10）的患者中，约 30%的患者会存在更高等级的癌症，并受益于治疗。这些患者可以通过重复活检、连续前列腺特异性抗原以及在临界病例中多参数 MRI 来识别。
总结：主动监测是解决与前列腺癌筛查相关的过度诊断和过度治疗问题的有效方法。对于 40-50%的低危前列腺癌患者，它提供了个体化医疗的好处，在大多数情况下避免了治疗和相关的生活质量影响，并为随着时间的推移被重新分类为高危疾病的少数患者提供了明确的管理。
