aDepartment of Urology, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden bDepartment of Surgery (Urology Service), Memorial Sloan-Kettering Cancer Center, New York, New York, USA.
Curr Opin Urol. 2014 May;24(3):256-63. doi: 10.1097/MOU.0000000000000054.
To describe mechanisms behind and extent of overdetection in prostate cancer screening as well as possible ways to avoid unnecessary overdiagnosis.
Overdetection and overtreatment is common in many areas of modern medicine. Current prostate-specific antigen (PSA) testing has resulted in a marked stage shift to early stages, which, together with improvements in treatment, has resulted in a substantial decrease in prostate cancer mortality. However, nonselective, widespread PSA-testing followed by liberal biopsy criteria has resulted in a high rate of overdiagnosis, which constitutes one major obstacle to introducing population-based screening.
Several steps are needed to decrease overdetection: do not screen elderly men unlikely to benefit, do not biopsy without a compelling reason, differentiate screening interval according to risk, work-up benign prostate disease by using reflex tests and/or complementary biomarkers, and focus on screening men at high risk for a life-threatening disease, for example evaluate men with above-median PSA levels in midlife. Recent results indicate that use of MRI to select men for biopsy and using only lesion-directed biopsies may be one way forward. However, more studies are needed before firm recommendations can be made. When the diagnosis is made, treat only those who need treatment. Tailor treatment to tumor biology and patient characteristics, and offer active surveillance to eligible men with low-risk tumors, especially small-volume disease, as the first management.
描述前列腺癌筛查中过度检测的机制和程度，以及避免不必要的过度诊断的可能方法。
过度诊断和过度治疗在现代医学的许多领域都很常见。目前的前列腺特异性抗原（PSA）检测导致了明显的分期向早期转移，这与治疗的改善一起，导致前列腺癌死亡率的大幅下降。然而，非选择性、广泛的 PSA 检测后进行广泛的活检标准导致了过度诊断的高发生率，这是引入基于人群的筛查的一个主要障碍。
需要采取几个步骤来减少过度检测：不筛查不太可能受益的老年男性，没有令人信服的理由不要进行活检，根据风险区分筛查间隔，通过反射测试和/或补充生物标志物来处理良性前列腺疾病，重点筛查患有危及生命疾病风险高的男性，例如评估中年时 PSA 水平高于中位数的男性。最近的结果表明，使用 MRI 选择进行活检的男性并仅进行针对病变的活检可能是一种方法。然而，在能够做出明确建议之前，还需要更多的研究。一旦做出诊断，只治疗那些需要治疗的患者。根据肿瘤生物学和患者特征来调整治疗方法，并为具有低风险肿瘤的合格男性提供主动监测，特别是对于小体积疾病，作为首选的治疗方法。
