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A discussion on controversies and ethical dilemmas in prostate cancer screening
  1. Satish Chandra Mishra
  1. Department of Surgery, WHO Collaboration Centre for Research in Surgical Care Delivery in LMIC, Bhabha Atomic Research Centre Hospital, Mumbai, MH 400094, India
  1. Correspondence to Dr Satish Chandra Mishra, Department of Surgery, WHO Collaboration Centre for Research in Surgical Care Delivery in LMIC, Bhabha Atomic Research Centre Hospital, Mumbai, MH 400094, India; mishrasatishdr{at}gmail.com

Abstract

Prostate cancer (PCa) is one of the the most common cancers in men. A blood test called prostate-specific antigen (PSA) has a potential to pick up this cancer very early and is used for screening of this disease. However, screening for prostate cancer is a matter of debate. Level 1 evidence from randomised controlled trials suggests a reduction in cancer-specific mortality from PCa screening. However, there could be an associated impact on quality of life due to a high proportion of overdiagnosis and overtreatment as part of the screening. The US Preventive Services Task Force (USPSTF) in 2012 recommended that PSA-based PCa screening should not to be offered at any age. However, considering the current evidence, USPSTF recently revised its recommendation to offer the PSA test to men aged 55–69 years with shared decision-making, in line with earlier guidelines from the American Cancer Society and the American Urological Association. A shared decision making is necessary since the PSA test could potentially harm an individual. However, the literature suggests that clinicians often neglect a discussion on this issue before ordering the test. This narrative discusses the main controversies regarding PCa screening including the PSA threshold for biopsy, the concept of overdiagnosis and overtreatment, the practical difficulties of active surveillance, the current level 1 evidence on the mortality benefit of screening, and the associated pitfalls. It offers a detailed discussion on the ethics involved in the PSA test and highlights the barriers to shared decision-making and possible solutions.

  • clinical ethics
  • surgery
  • decision-making
  • education for health care professionals
  • public health ethics
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Footnotes

  • Contributors I am the sole author. I conceptualised and developed the project design, surveyed the literature, prepared the draft and finalised the manuscript.

  • Funding The author has not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement statement No patient was involved in the preparation of this manuscript.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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