The controversy surrounding prostate cancer screening stems in part from the different perspectives of health care policy analysts, practicing clinicians, patients, health insurers, and government agencies. Those who advocate screening emphasize the significant morbidity and mortality associated with prostate cancer. They believe that the current level of experimental evidence supports the concept that aggressive intervention dramatically improves survival among men diagnosed with early-stage disease compared with a more conservative approach, which deals with the clinical manifestations of the natural progression of the disease.<sup>5 Andriole G.L., Catalona W.J. Using PSA to screen for prostate cancer Urol Clin North Am 1993 ;  20 : 647-651

Cliccare qui per andare alla sezione Riferimenti, 13 Catalona W.J. Screening for prostate cancer: Enthusiasm [editorial] Urology 1993 ;  42 : 113-115  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti, 41 Littrup P.J., Goodman A.C., Mettlin C.J. The benefit and cost of prostate cancer early detection CA Cancer J Clin 1993 ;  43 : 134-149  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti, 53 Slawin K.M., Ohori M., Dillioglugil O., Scardino P.T. Screening for prostate cancer: An analysis of early experience CA Cancer J Clin 1995 ;  45 : 134-147  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti, 58 Walsh P.C. Prostate cancer kills: Strategy to reduce deaths Urology 1994 ;  44 : 463-466  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti</sup> Those who oppose prostate cancer screening emphasize the lack of experimental evidence supporting the theory that early detection and treatment of this disease substantially lowers cause-specific mortality. They point to the significant morbidity associated with current treatment efforts and conclude that screening is unethical because there is a high probability that screening may cause more harm than good.<sup>2 Adami H.O., Baron J.A., Rothman K.J. Ethics of a prostate cancer screening trial Lancet 1994 ;  343 : 958-960  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti, 18 Chodak G.W. Questioning the value of screening for prostate cancer in asymptomatic men Urology 1993 ;  42 : 116-118  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti, 21 Denis L.J. To screen or not to screen? Prostate Suppl 1992 ;  4 : 63-70  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti, 30 Gerber G.S., Chodak G.W. Routine screening for cancer of the prostate J Natl Cancer Inst 1991 ;  83 : 329-335  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti, 32 Gohagan J.K., Kramer B.S., Greenwald P. Screening for prostate cancer Am J Prev Med 1994 ;  10 : 245-246

Cliccare qui per andare alla sezione Riferimenti, 36 Hinman F. Screening for prostatic carcinoma J Urol 1991 ;  145 : 126-130

Cliccare qui per andare alla sezione Riferimenti, 56 US Preventive Services Task Force Screening for prostate cancer: Commentary on the recommendations of the Canadian Task Force on the Periodic Health Examination Am J Prev Med 1994 ;  10 : 187-193

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This debate also exists within a larger discussion concerning the appropriate use of resources within our health care system. Western societies face extraordinary pressures to control health care budgets. Within the United States, legislators have proposed dramatic changes in Medicare and Medicaid, and managed care companies are exploring methods to reign in burgeoning health care expenses. Until recently, society has encouraged clinicians and researchers to do all that was possible to fight disease. Medical interventions based on reasonably sound pathophysiologic principles were often championed until clinical trials proved them worthless. This paradigm has begun to shift in favor of one that has clinicians withhold therapy until scientific evidence supports the benefit of intervention. Eddy<sup>24 Eddy D.M. Clinical decision making: Principles for making difficult decisions in difficult times JAMA 1994 ;  271 : 1792-1798

Cliccare qui per andare alla sezione Riferimenti</sup> has suggested that health care costs can be controlled only when health care allocations are based on the following three principles: (1) there should be convincing evidence that, compared with no treatment, the treatment is effective in improving health outcomes; (2) compared with no treatment, its beneficial effects on health outcomes should outweigh any harmful effects on health outcomes; and (3) compared with the next best alternative treatment, the treatment should represent a good use of resources in the sense that it maximizes the health of the population served, subject to the available resources. Furthermore, he emphasizes that the “burden of proof” justifying medical intervention now rests with those who promote treatment.<sup>23 Eddy D.M. Clinical decision making: From theory to practice; three battles to watch in the 1990's JAMA 1993 ;  270 : 520-526

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Within this context, I argue that screening for prostate cancer cannot be justified from a health policy standpoint because the resources necessary to implement a screening program are excessive compared with other demands being placed on health care budgets. Anecdotal support for screening based on individual patients who appear to have benefited from early detection and intervention will always exist. The answer to the more difficult health care policy questions surrounding screening, however, rests on randomized clinical trials and careful, systematic analyses of alternative treatment strategies.

Without some attempt at measurement, the uncertainty surrounding cost-benefit estimates can be dramatic. Readers need only reflect on an earlier American Cancer Society endorsement of a protocol proposing six sequential stool tests for the detection of colon cancer. This protocol appeared to have reasonable face validity until Neuhauser and Lewicki<sup>45 Neuhauser D., Lewicki A.M. What do we gain from the sixth stool quaiac? N Engl J Med 1975 ;  293 : 226-228  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti</sup> demonstrated that the cost per case detected would reach $47 million for the sixth test. Recent published estimates concerning prostate cancer screening suggest that one-time prostate cancer screening for the US male population over 50 years old would cost $12 to 28 billion dollars.<sup>22 Dorr V.J., Williamson S.K., Stephens R.L. An evaluation of prostate-specific antigen as a screening test for prostate cancer Arch Intern Med 1993 ;  153 : 2529-2537

Cliccare qui per andare alla sezione Riferimenti, 40 Kramer B.S., Brown M.L., Prorok P.C. , e al. Prostate cancer screening: What we know and what we need to know Ann Intern Med 1993 ;  119 : 914-923

Cliccare qui per andare alla sezione Riferimenti, 47 Optenburg S.A., Thompson I.M. Economics of screening for carcinoma of the prostate Urol Clin North Am 1990 ;  17 : 719-737

Cliccare qui per andare alla sezione Riferimenti</sup> Although some lives may be saved, we must reflect carefully whether this enormous expenditure of resources is justified by a commensurate improvement in the health status of individuals. Alternative investments of these resources that may be worth considering include an increase in basic science research funding to identify potential genetic cures for this disease.