Screening for Prostate Cancer: Intermediate Outcome Measures and Active Surveillance

Prostate cancer is the most frequently diagnosed cancer in men in the Western world. The increasing use of PSA as a screening test for this disease has contributed to a marked increase in the number of newly diagnosed prostate cancers in countries where screening is prevalent. Whether screening actually influences prostate cancer mortality is still unclear. Regardless of the conclusions of ongoing trials on this question, it is likely that opportunistic screening will continue to be used. A confirmed positive effect of screening on the disease specific mortality would give a population based screening program a stronger scientific basis. The disputable performance of the PSA test, the high prevalence of the disease in older men, together with a high incidence-to mortality ratio have confronted the medical community and especially the urological world with new dilemmas. Until new predictors become available which are capable of only detecting the significant prostate cancers, the high incidence, the serious side effects of prostate cancer treatments, costs, and especially the ethical aspects oblige us to consider the disadvantages of the currently used screening tools for prostate cancer. Overdiagnosis is one of the main problems. Ideally, detection of insignificant cancers could be avoided, but that is not presently possible, and therefore a likely by-product of a PSA screening program will be the frequent diagnosis of insignificant cancers. This thesis focuses on active surveillance as a way out of the screening dilemma described above. Active surveillance manages selected men with prostate cancer expectantly with curative intent. These carefully selected men are actively observed in order to have the possibility to offer them deferred curative treatment once the tumour seems to progress. This thesis explores what kind of cancers are diagnosed by screening, how to subsequently risk-stratify those and what the best strategy is for active surveillance of a subset of these cancers.

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