Van Poppel Hendrik, Albreht Tit, Basu Partha, Hogenhout Renée, Collen Sarah, Roobol Monique
Department of Urology, Katholieke Universiteit Leuven, Leuven, Belgium.
National Institute of Public Health, Ljubljana, Slovenia.
Nat Rev Urol. 2022 Sep;19(9):562-572. doi: 10.1038/s41585-022-00638-6. Epub 2022 Aug 16.
In the pre-PSA-detection era, a large proportion of men were diagnosed with metastatic prostate cancer and died of the disease; after the introduction of the serum PSA test, randomized controlled prostate cancer screening trials in the USA and Europe were conducted to assess the effect of PSA screening on prostate cancer mortality. Contradictory outcomes of the trials and the accompanying overdiagnosis resulted in recommendations against prostate cancer screening by organizations such as the United States Preventive Services Task Force. These recommendations were followed by a decline in PSA testing and a rise in late-stage diagnosis and prostate cancer mortality. Re-evaluation of the randomized trials, which accounted for contamination, showed that PSA-based screening does indeed reduce prostate cancer mortality; however, the debate about whether to screen or not to screen continues because of the considerable overdiagnosis that occurs using PSA-based screening. Meanwhile, awareness among the population of prostate cancer as a potentially lethal disease stimulates opportunistic screening practices that further increase overdiagnosis without the benefit of mortality reduction. However, in the past decade, new screening tools have been developed that make the classic PSA-only-based screening an outdated strategy. With improved use of PSA, in combination with age, prostate volume and with the application of prostate cancer risk calculators, a risk-adapted strategy enables improved stratification of men with prostate cancer and avoidance of unnecessary diagnostic procedures. This combination used with advanced detection techniques (such as MRI and targeted biopsy), can reduce overdiagnosis. Moreover, new biomarkers are becoming available and will enable further improvements in risk stratification.
在前列腺特异性抗原（PSA）检测时代之前，很大一部分男性被诊断为转移性前列腺癌并死于该疾病；血清PSA检测引入后，美国和欧洲开展了随机对照前列腺癌筛查试验，以评估PSA筛查对前列腺癌死亡率的影响。试验结果相互矛盾以及随之而来的过度诊断，导致美国预防服务工作组等组织建议不进行前列腺癌筛查。这些建议导致PSA检测减少，晚期诊断和前列腺癌死亡率上升。对考虑了污染因素的随机试验进行重新评估后发现，基于PSA的筛查确实能降低前列腺癌死亡率；然而，由于基于PSA的筛查会出现相当多的过度诊断情况，关于是否进行筛查的争论仍在继续。与此同时，公众对前列腺癌作为一种潜在致命疾病的认知促使了机会性筛查行为，这进一步增加了过度诊断，却没有降低死亡率的益处。然而，在过去十年中，已经开发出了新的筛查工具，使得仅基于经典PSA的筛查成为一种过时的策略。通过更好地利用PSA，并结合年龄、前列腺体积以及应用前列腺癌风险计算器，一种风险适应性策略能够改善前列腺癌男性的分层，并避免不必要的诊断程序。这种与先进检测技术（如MRI和靶向活检）结合使用的方法，可以减少过度诊断。此外，新的生物标志物正在出现，并将进一步改善风险分层。
