Many of the almost 100 reports in various journals and newspapers refer to the lack of effect on overall mortality with screening in ERSPC in a very critical fashion. Clarification is necessary. Our trial did not intend to and is not powered to study the effect of screening on overall mortality. Mortality from all causes contributes about 30% to overall male mortality. To decrease cancer mortality in general is an explicit goal in most countries of the world. Prostate cancer mortality is in most countries the second or third most frequent cause of cancer-related death in males. We wished and still wish to contribute to its decrease at an acceptable price in terms of harm and costs. Unfortunately, as stated in the conclusions in our New England Journal of Medicine article, the time of population-based screening has not (yet) come.
Role of Risk Calculators
The decrease of harms, mainly overdiagnosis and overtreatment in large proportions of men with screening-detected prostate cancers, which is quantified reliably through ERSPC data for the first time, requires the intensive cooperative efforts of our profession and of related basic research. As long as a simple blood test or another means of selective identification of the more aggressive but still curable lesions does not exist, available risk calculators that allow avoiding “unnecessary” diagnostic steps should be widely applied in a concerted way. An example is the risk calculator available at www.prostatecancer-riskcalculator.com. This calculator is based on ERSPC data and has been repeatedly externally validated.
Implications of the Data
So, how should the public and how should our colleagues deal with the new information? The authors feel that for men who consider being screened, the positive side of the argument has changed: We showed that in men actually screened, there was a highly significant prostate cancer mortality reduction. The downside has remained unchanged. This requires rather difficult informed decision-making.
There is a need for international standardization of the related information for “the man on the street” and for his consulted health professionals. Fortunately, the International Society of Urology, which represents 111 countries, has decided to produce and to distribute such information in 2012-2013. ■
Disclosure: Dr. Schröder reported no potential conflicts of interest with respect to this commentary or the ERSPC study report.
Dr. Schröder is Professor of Urology at Erasmus Medical Center, Rotterdam, the Netherlands.
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