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European UrologyVolume 62, issue 2, pages e31-e48, August 2012
Reply from Authors re: Peter C. Albertsen. How Best To Use Our Tools? Eur Urol 2012;62:201–2
Published online 13 March 2012, page 203
Refers to article:
How Best To Use Our Tools?
August 2012 (Vol. 62, Issue 2, pages 201 - 202)
Refers to article:
Radical Prostatectomy for Low-Risk Prostate Cancer Following Initial Active Surveillance: Results From a Prospective Observational Study
Accepted 5 February 2012
August 2012 (Vol. 62, Issue 2, pages 195 - 200)
We appreciate the comments from Albertsen  in response to our paper . He highlighted some of the controversies and obstacles in prostate cancer (PCa) screening that have yet to be conquered . Although it has been shown that screening for PCa can reduce disease-specific mortality by up to 30%  and  or even more  and , the shortcomings of screening regarding the number of false-positive tests and overdiagnosis are evident. Hence we are aware of the side effects of screening, and the challenge we face is to look for solutions.
There is still a lot of work to do in finding new, better, and more selective markers for screening purposes and to keep improving nomograms for risk stratification to achieve better predictions . Ideally, either there would be no overdetection of disease that will not surface clinically during the patient's lifetime or radical treatment would be free from any side effects. Unfortunately, to date, neither of these ideals can be realized.
In that respect, we have to keep both feet on the ground and acknowledge that there is no time to wait for scientific certainty; no perfect marker is available for selective detection of significant PCa, and such a marker might never be found. Consequently, in current practice, we shall make do with what we have and implement the best available evidence in practice. For now, this implies that decisions about screening should be made on an individual basis, after providing the patient with information about his potential risks and benefits.
Even though the natural course of PCa is not completely clear, it is plain to see that in the prostate-specific antigen era, a lot of indolent disease is being detected, making active surveillance (AS) a sensible alternative as a management strategy for patients in whom such low-risk disease is suspected.
Regarding the considerable difficulties in implementing trials randomizing for radical treatment and AS , answers to important questions on long-term mortality and inclusion and follow-up criteria for AS are more likely to come from prospective AS studies . We hope that with the data of our Web-based, multinational Prostate Cancer Research: Active Surveillance (PRIAS) study, we will contribute to the improvement of eligibility criteria and follow-up protocols for men with favorable-risk disease.
In the meantime, the search for the perfect marker continues, and we will carry on with providing the best care available today to our patients.
Conflicts of interest
The authors have nothing to disclose.
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-  Klotz L, Kibel A, Sanda M. Observation or radical treatment in patients with prostate cancer [identifier NCT00499174]. ClinicalTrials.gov Web site. http://clinicaltrials.gov/ct2/show/NCT00499174?term=NCT00499174&rank=1.
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Department of Urology, Erasmus MC, Rotterdam, The Netherlands
© 2012 European Association of Urology, Published by Elsevier B.V.
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