Department of Surgery (Urology), UConn Health, Farmington, CT, USA.
BJU Int. 2020 Aug;126(2):218-224. doi: 10.1111/bju.15153. Epub 2020 Jul 27.
To evaluate the current prostate cancer screening and treatment paradigm in light of recently published long-term results of major screening and treatment trials.
Historical review of the evolution of the diagnosis and treatment of prostate cancer followed by a detailed summary of the findings and differences among the three major screening trials and the three major treatment trials.
Prostate-specific antigen (PSA) testing can identify clinically significant prostate cancer and has produced a significant stage shift and is the likely explanation for the decline in prostate cancer mortality. Unfortunately, PSA testing predominantly identifies low-grade disease that is unlikely to progress during a patient's lifetime leading to substantial diagnosis of indolent disease. Treatment with radical prostatectomy (RP) appears to benefit primarily younger men (aged <65 years) with intermediate-grade disease. Too few men with low-grade disease benefit from RP to justify intervening in all. Unfortunately, high-grade prostate cancer often progresses despite surgery and radiation.
The primary PSA testing paradigm is wrong. Rather than attempting to identify all prostate cancers as early as possible, testing objectives should shift towards identifying men likely to harbour clinically significant disease. These are the men who appear to benefit from early diagnosis and intervention, including the earlier use of antiandrogen therapy prior to widespread metastases.
根据最近发表的主要筛查和治疗试验的长期结果，评估当前的前列腺癌筛查和治疗模式。
对前列腺癌诊断和治疗演变的历史回顾，随后详细总结了三项主要筛查试验和三项主要治疗试验的发现和差异。
前列腺特异性抗原（PSA）检测可以识别有临床意义的前列腺癌，并已产生显著的分期转变，这可能是前列腺癌死亡率下降的原因。不幸的是，PSA 检测主要识别低级别疾病，这些疾病在患者的一生中不太可能进展，导致大量的惰性疾病被诊断出来。根治性前列腺切除术（RP）治疗似乎主要对年龄<65 岁的中级别疾病的年轻男性有益。接受 RP 治疗的低级别疾病患者获益太少，无法证明对所有患者进行干预是合理的。不幸的是，即使进行了手术和放疗，高级别前列腺癌仍常常进展。
主要的 PSA 检测模式是错误的。检测目标不应试图尽早识别所有前列腺癌，而应转向识别可能患有有临床意义疾病的男性。这些男性似乎受益于早期诊断和干预，包括在广泛转移之前更早地使用抗雄激素治疗。
