Prostate cancer, a disease that has increasingly affected the health of middle-aged and older men in China in recent years. According to the World Health Organization’s International Agency for Research on Cancer, the incidence of prostate cancer in China in 2020 is about 15.6 per 100,000 people, with higher rates in first-tier cities such as Beijing, Shanghai and Guangzhou. And the 2020 World Cancer Report shows that prostate cancer ranks 6th in incidence and 9th in mortality of malignant tumors in men.
However, the clinical staging of patients diagnosed with prostate cancer for the first time in China differs greatly from that in Western countries – more Chinese patients diagnosed with prostate cancer for the first time are already in the mid- to late-stage and have a relatively poorer prognosis, while some countries that started their prostate cancer screening strategies earlier have a much better overall prognosis for prostate cancer than China. The overall prognosis for prostate cancer is much better than in China.
For example, the 5-year survival rate for prostate cancer in Japan is 93.0%, compared with 69.2% in China. In the United States, prostate cancer mortality has decreased by 51% between 1993 and 2016 since prostate cancer screening was introduced.
Theoretically, screening for prostate cancer helps achieve early detection, early diagnosis, and early treatment of prostate cancer, which can improve treatment outcomes and prognosis for prostate cancer. But is this really the case? Does prostate cancer screening really improve overall patient survival and reduce the number of deaths caused by prostate cancer?
Does prostate cancer detected by PSA screening have to be treated?
While there is no cure for cancer, there is a consensus among physicians that early detection, diagnosis, and treatment are important for controlling the progression of cancer. In addition, there are internationally recognized effective screening methods for breast, cervical, colon, and lung cancers that can help raise the alarm early.
One mainstream approach to screening for prostate cancer is to perform a prostate-specific antigen (PSA) test. Since the early 1990s, when it was discovered that such a simple blood test could detect prostate cancer risk, it quickly became a worldwide sensation and a boon to men.
But a significant proportion of patients who are ultimately diagnosed with prostate cancer through PSA screening are neither aggressive nor life-threatening, and it is a “fairly lazy” cancer. Even among men aged 70 years or older who died of other causes, more than one-third were found at autopsy to have had prostate cancer that was unknown during their lifetime. As a result, computer modeling studies estimate that 23% to 50% of prostate cancers may be “overdiagnosed.
The downside of this “overdiagnosis” is clear: when a biopsy is performed because of elevated PSA, and prostate cancer is eventually confirmed, it can cause considerable anxiety in the patient, even if the cancer progresses rather slowly and does not even become the ultimate cause of death. Some male patients may undergo and unnecessary treatment as a result, and lead to impotence, urinary incontinence, etc.
So in recent years, many scholars have begun to question whether annual PSA testing of men in general and biopsy of screened high-risk patients is really necessary.
Together with MRI-targeted biopsies, results may be more meaningful
A recent study of screening tools for prostate cancer was recently published in the New England Journal of Medicine, the world’s top medical journal. The results suggest that if magnetic resonance imaging (MRI)-targeted biopsies are used in conjunction with PSA, they may reduce the disadvantages of such screening.
So, how did this study go?
In detecting clinically significant prostate cancer, MRI followed by targeted and standard biopsies did not lose out to traditional standard biopsies and reduced the detection rate of “lazy” cancers. The authors also concluded that the additional cost of MRI could be offset by the medical cost savings of reducing overtreatment.
Huang Xiaobo, director of the Center for Urology and Lithotripsy at Peking University People’s Hospital, commented that it is a difficult question to consider whether to perform a standard 12-stitch puncture directly or a standard puncture combined with MRI-targeted puncture when a patient meets the indications for prostate puncture. The present study provides a good solution for clinicians. Although MRI fusion-targeted puncture is not yet widely performed in China, cognitive fusion imaging-targeted prostate puncture does not require special equipment or software, which is consistent with the basic situation in China and can be actively promoted.
In the face of uncertainty about prostate cancer screening and treatment, it is difficult for patients to make decisions for themselves. In particular, men who are detected with “lazy” prostate cancer do have to weigh the side effects of urinary, bowel, and sexual function against the risk of metastasis and progression later in life. There are complex scientific data, life values, and economic factors involved, and this has led to a continuing debate.