Diagnosis, management and screening of early localised prostate cancer.
Health Technol Assess (Winch Eng) 1997;1(2):i, 1-96

Selley S; Donovan J; Faulkner A; Coast J; Gillatt D
Department of Social Medicine, University of Bristol.

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 confirmat-
ion 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 introduct-
ion 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. (432 Refs)