Selley S, Donovan J, Faulkner A, Coast J, Gillatt D
Department of Social Medicine, University of Bristol.
Health Technol Assess. 1997;1(2):i, 1-96.
The incidence of prostate cancer is rising worldwide, caused mainly by demographic factors, particularly the increasingly elderly population and, more importantly, the increasing number of cases identified following prostate specific antigen (PSA) testing. It is commonly quoted that many more men die with prostate cancer than of it. Autopsy/post-mortem studies show that while a very high proportion of elderly men have histological evidence of the disease, a much smaller proportion develop clinically apparent cancer. The natural history of prostate cancer is poorly understood, but progression appears to be related to stage and grade of tumour. Prostate cancer can be diagnosed by digital rectal examination (DRE), serum PSA test, and/or transrectal ultrasound (TRUS), with confirmation by biopsy. Each test identifies a proportion of cancers, with higher rates of detection when they are used in combination. The tests are also used to determine which tumours are localised within the prostate and are, thus, potentially treatable. Unfortunately, clinical staging is unreliable, with approximately one half of all tumours upstaged following surgery. Three major treatment options are available for localised prostate cancer: radical prostatectomy, radical radiotherapy and conservative management (involving monitoring and treatment of symptoms). Although radical treatment rates are rising, good quality evidence concerning their comparative effectiveness and cost-effectiveness is lacking. Observational studies of highly selected patient groups suggests that there may be a slightly lower mortality rate following radical treatments compared with conservative management, but there has been very little research into treatment complications and quality of life of men after any of the treatments. In the past, investigations of prostate cancer were reserved largely for patients exhibiting symptoms, but the introduction of the PSA test has opened up the possibility of screening healthy men for the disease. Observational studies suggest that DRE and PSA, combined with TRUS and biopsy, can identify localised prostate cancer in 3-5% of men, although the tests do result in a number of false positives and negatives. Major questions remain concerning the natural history of the disease, potential costs (financial, social and psychological) of a screening programme, and the effectiveness and cost-effectiveness of treatments for localised disease. The lack of good quality data and the strength of these concerns means that population screening for prostate cancer cannot be recommended.
全球范围内前列腺癌的发病率正在上升，主要由人口统计学因素导致，特别是人口老龄化加剧，更重要的是，前列腺特异性抗原（PSA）检测后确诊的病例数不断增加。人们普遍认为，死于前列腺癌的男性比因前列腺癌而死亡的男性多得多。尸检研究表明，虽然很大比例的老年男性有该疾病的组织学证据，但临床上出现明显癌症的比例要小得多。前列腺癌的自然病程了解甚少，但进展似乎与肿瘤的分期和分级有关。前列腺癌可通过直肠指检（DRE）、血清PSA检测和/或经直肠超声（TRUS）诊断，并通过活检确诊。每项检测都能发现一定比例的癌症，联合使用时检测率更高。这些检测还用于确定哪些肿瘤局限于前列腺内，因此有可能得到治疗。不幸的是，临床分期并不可靠，所有肿瘤中约有一半在手术后被上调分期。局限性前列腺癌有三种主要治疗选择：根治性前列腺切除术、根治性放疗和保守治疗（包括监测和症状治疗）。尽管根治性治疗率在上升，但缺乏关于其相对有效性和成本效益的高质量证据。对高度选择的患者群体的观察性研究表明，与保守治疗相比，根治性治疗后的死亡率可能略低，但对于任何一种治疗后男性的治疗并发症和生活质量的研究很少。过去，前列腺癌的研究主要针对出现症状的患者，但PSA检测的引入为筛查健康男性是否患有该疾病提供了可能。观察性研究表明，DRE和PSA联合TRUS及活检可在3%至5%的男性中发现局限性前列腺癌，尽管这些检测确实会产生一些假阳性和假阴性结果。关于该疾病的自然病程、筛查计划的潜在成本（经济、社会和心理）以及局限性疾病治疗的有效性和成本效益，仍存在重大问题。缺乏高质量数据以及这些问题的严重性意味着不建议对前列腺癌进行人群筛查。
