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European UrologyVolume 49, issue 2, pages 209-414, February 2006
Words of Wisdom
Incidence and Follow-Up of Patients with Focal Prostate Carcinoma in 2 Screening Rounds After an Interval of 4 Years
Postma R, de Vries SH, Roobol MJ, Wildhagen MF, Schröder FH, van der Kwast TH
This study evaluated the clinicopathologic features of patients with focal carcinoma (≤3.0 mm in only one core of sextant biopsies, lacking Gleason patterns 4 and 5). The patients underwent radical prostatectomy (RP, n = 103) or were monitored regularly (the “wait and watch” method [WW], n = 108). RP specimens were categorized into minimal tumours (volume <0.5 ml, no Gleason patterns 4 and 5, organ confined, and negative surgical margins) or moderate-to-advanced tumours (volume ≥0.5 ml, Gleason pattern 4 or 5 detectable, extracapsular extension, or positive surgical margins). The median tumour volume in RP specimens was 0.13 ml, and in 78.6% of the cases it was <0.5 ml. In 3 specimens, no tumour was found. A prostate-specific antigen (PSA) density cutoff level of ≤0.1 ng/ml/cm3 predicted a tumour volume of <0.5 ml in 94% of cases. Because it was part of the European Randomized Screening Study for Prostate Cancer, the study also showed that the proportion of patients with focal prostate carcinoma increased significantly, from 16% during the first screening round to 29% during the second round, 4 years later. The median tumour volume in the first round (PSA ≥ 4) was 0.16 ml, and that in the second round (PSA ≥ 3) was 0.07 ml, but this difference did not reach statistical significance.
The authors concluded that the WW policy with delayed curative intent may be recommended in patients 55–75 yr old who have focal carcinoma and a PSA density <0.1 ng/ml/cm3. Natural-history data from other cohorts have shown the indolent character of low-grade prostate cancer, with 15-year disease-specific survival rates of approximately 80%  and . The follow-up time of the present study is still short, and the mortality in the RP and WW groups cannot be analyzed yet. A Scandinavian randomized study  showed better results for patients with RP, but most cancers were clinically detectable. Even then, because of a small absolute reduction in prostate cancer mortality, 19 patients needed to be treated to prevent one death at 10 years. Respective speculations for today's low-risk small tumours increase this number to 100 patients . This is ethically unacceptable. It is impossible to stop prostate cancer screening, but if the PSA threshold is lowered from 4 to 3 or even lower, and 12 biopsies are routinely done, we are going to find a large number of insignificant cancers. Surgeons like to operate, but it is not meaningful to shoot mosquitoes with a cannon. Proper guidelines for screening and the WW policy are urgently needed.
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-  A. Bill-Axelson, et al. Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med. 2005;352:1977-1984 Crossref.
-  L. Klotz. Active surveillance for prostate cancer: for whom?. J Clin Oncol. 2005;23:8165-8169 Crossref.
Department of Urology, Helsinki University Hospital, Finland
© 2006 Published by Elsevier B.V.
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