The Dark Side of Prostate Cancer Screening: An Epidemic of Overdiagnosis & Overtreatment

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Imagine being told you have cancer, undergoing invasive treatments, and living with the side effects, only to later discover that your cancer would have never caused any symptoms or threatened your life. This is the reality for countless men diagnosed with prostate cancer, falling victim to the epidemic of overdiagnosis.

Introduction: Defining Overdiagnosis

Overdiagnosis is the diagnosis of a condition that would not have caused symptoms or death during a patient's lifetime.1 In the context of prostate cancer, overdiagnosis occurs when screening tests, such as prostate-specific antigen (PSA) testing, detect slow-growing, non-aggressive tumors that would have never progressed or caused harm.2

The Background of Prostate Cancer Overdiagnosis

The widespread use of PSA testing for prostate cancer screening has led to a significant increase in prostate cancer diagnoses. However, many of these diagnosed cancers are indolent and would not have caused symptoms or death if left undetected.3 This overdiagnosis subjects men to unnecessary biopsies, treatments, and potential side effects, impacting their quality of life.4

The Prevalence of Overdiagnosis

Studies have consistently shown that prostate cancer overdiagnosis is a significant problem. A systematic review by Ilic et al. found that PSA screening resulted in a 50% increase in prostate cancer diagnoses, with an estimated overdiagnosis rate of 30-50%.5 Similarly, the European Randomized Study of Screening for Prostate Cancer (ERSPC) reported that for every 1,000 men screened, 34 additional prostate cancer cases were diagnosed, translating to a substantial overdiagnosis burden.6

A study by Hugosson et al. evaluating the long-term outcomes of the Göteborg Randomized Population-based Prostate Cancer Screening Trial found that after 18 years of follow-up, the excess incidence of prostate cancer in the screening group compared to the control group was 34 cases per 1,000 men, indicating a significant level of overdiagnosis.7

In the U.S. Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, Pinsky et al. reported that after 13 years of follow-up, the risk of being diagnosed with prostate cancer was 12% higher in the screening group compared to the control group, with no significant difference in prostate cancer-specific mortality, suggesting substantial overdiagnosis.8

A modeling study by Etzioni et al. estimated that in the United States, the overdiagnosis rate among screen-detected prostate cancers was 23-42%, depending on the method used to estimate lead time and the PSA screening intensity.9 These findings highlight the pervasive nature of prostate cancer overdiagnosis and the need for strategies to mitigate this problem.

The Consequences of Overtreatment

Overdiagnosis often leads to overtreatment, as many men with indolent tumors undergo invasive procedures such as prostate biopsies, surgery, or radiation therapy. The ProtecT trial demonstrated that active monitoring, surgery, and radiotherapy resulted in similar prostate cancer-specific mortality rates after 10 years, highlighting the potential for overtreatment.10 Overtreatment exposes men to unnecessary risks, including urinary incontinence, erectile dysfunction, and bowel problems.11

Alternative Perspectives on Prostate Health

While the mainstream medical approach to prostate cancer focuses on early detection and treatment, some researchers and authors have proposed alternative perspectives on prostate health and disease prevention. In his critically acclaimed book "Regenerate: Unlocking Your Body's Radical Resilience through the New Biology," Sayer Ji presents a different view of cancer and explores the body's innate ability to prevent and heal from chronic diseases, including cancer.17 This work, which includes hundreds of scientific references, challenges conventional understanding of cancer and highlights the importance of a holistic approach to health and disease prevention. You can also review the Prostate Cancer database on Greenmedinfo.com which houses over 1,000 studies across ~400 natural substances relevant to prostate tissue abnormalities, including those conventionally defined as "cancer." 

Strategies to Reduce Overdiagnosis

To combat the prostate cancer overdiagnosis epidemic, several strategies have been proposed. Risk stratification tools, such as the 4Kscore and Stockholm-3 tests, can help identify men at higher risk of aggressive prostate cancer, reducing unnecessary biopsies.12 Additionally, the use of magnetic resonance imaging (MRI) before biopsy can improve the detection of clinically significant cancers while reducing the diagnosis of indolent tumors.13 Active surveillance, which involves closely monitoring low-risk tumors instead of immediate treatment, has emerged as a viable option to mitigate overtreatment.14 "Watchful waiting" as it is called, when combined with dietary changes and natural health approaches, including detoxification protocols, could result in significantly improved outcomes relative to conventional approaches. 

Ongoing Trials and Future Directions

Several ongoing trials aim to address the prostate cancer overdiagnosis problem. The ProScreen trial in Finland and the Göteborg-2 trial in Sweden are evaluating the effectiveness of PSA screening combined with additional biomarkers and MRI to reduce overdiagnosis.15 These trials, along with others like the PROBASE trial in Germany, will provide valuable insights into optimizing prostate cancer screening strategies.16

Conclusion

Prostate cancer overdiagnosis has reached epidemic proportions, with significant consequences for men's health and quality of life. The current evidence highlights the urgent need for a paradigm shift in prostate cancer screening and management. Continuing to rely on PSA testing as the primary screening tool will perpetuate the overdiagnosis epidemic and subject countless men to unnecessary interventions and potential harm. It is crucial for healthcare professionals, policymakers, and patient advocates to collaborate and critically evaluate the current approach to prostate cancer screening, seeking alternative strategies that prioritize the well-being and informed decision-making of patients.  


References

1: Welch HG, Black WC. Overdiagnosis in cancer. Journal of the National Cancer Institute. 2010;102(9):605-613. https://doi.org/10.1093/jnci/djq099

2: Loeb S, Bjurlin MA, Nicholson J, et al. Overdiagnosis and overtreatment of prostate cancer. European Urology. 2014;65(6):1046-1055. https://doi.org/10.1016/j.eururo.2013.12.062

3: Draisma G, Etzioni R, Tsodikov A, et al. Lead time and overdiagnosis in prostate-specific antigen screening: importance of methods and context. Journal of the National Cancer Institute. 2009;101(6):374-383. https://doi.org/10.1093/jnci/djp001

4: Carter HB, Albertsen PC, Barry MJ, et al. Early detection of prostate cancer: AUA guideline. Journal of Urology. 2013;190(2):419-426. https://doi.org/10.1016/j.juro.2013.04.119

5: Ilic D, Neuberger MM, Djulbegovic M, Dahm P. Screening for prostate cancer. Cochrane Database of Systematic Reviews. 2013;(1):CD004720. https://doi.org/10.1002/14651858.CD004720.pub3

6: Schröder FH, Hugosson J, Roobol MJ, et al. Screening and prostate cancer mortality: results of the European Randomised Study of Screening for Prostate Cancer (ERSPC) at 13 years of follow-up. The Lancet. 2014;384(9959):2027-2035. https://doi.org/10.1016/S0140-6736(14)60525-0

7: Hugosson J, Godtman RA, Carlsson SV, et al. Eighteen-year follow-up of the Göteborg Randomized Population-based Prostate Cancer Screening Trial: effect of sociodemographic variables on participation, prostate cancer incidence and mortality. Scandinavian Journal of Urology. 2018;52(1):27-37. https://doi.org/10.1080/21681805.2017.1411392

8: Pinsky PF, Prorok PC, Yu K, et al. Extended mortality results for prostate cancer screening in the PLCO trial with median follow-up of 15 years. Cancer. 2017;123(4):592-599. https://doi.org/10.1002/cncr.30474

9: Etzioni R, Gulati R, Mallinger L, Mandelblatt J. Influence of study features and methods on overdiagnosis estimates in breast and prostate cancer screening. Annals of Internal Medicine. 2013;158(11):831-838. https://doi.org/10.7326/0003-4819-158-11-201306040-00008

10: Hamdy FC, Donovan JL, Lane JA, et al. 10-year outcomes after monitoring, surgery, or radiotherapy for localized prostate cancer. New England Journal of Medicine. 2016;375(15):1415-1424. https://doi.org/10.1056/NEJMoa1606220

11: Donovan JL, Hamdy FC, Lane JA, et al. Patient-reported outcomes after monitoring, surgery, or radiotherapy for prostate cancer. New England Journal of Medicine. 2016;375(15):1425-1437. https://doi.org/10.1056/NEJMoa1606221

12: Nordström T, Vickers A, Assel M, Lilja H, Grönberg H, Eklund M. Comparison between the four-kallikrein panel and prostate health index for predicting prostate cancer. European Urology. 2015;68(1):139-146. https://doi.org/10.1016/j.eururo.2014.08.010

13: Kasivisvanathan V, Rannikko AS, Borghi M, et al. MRI-targeted or standard biopsy for prostate-cancer diagnosis. New England Journal of Medicine. 2018;378(19):1767-1777. https://doi.org/10.1056/NEJMoa1801993

14: Klotz L, Vesprini D, Sethukavalan P, et al. Long-term follow-up of a large active surveillance cohort of patients with prostate cancer. Journal of Clinical Oncology. 2015;33(3):272-277. https://doi.org/10.1200/JCO.2014.55.1192

15: Auvinen A, Rannikko A, Taari K, et al. A randomized trial of early detection of clinically significant prostate cancer (ProScreen): study design and rationale. European Journal of Epidemiology. 2017;32(6):521-527. https://doi.org/10.1007/s10654-017-0269-4

16: Arsov C, Becker N, Hadaschik BA, et al. Prospective randomized evaluation of risk-adapted prostate-specific antigen screening in young men: the PROBASE trial. European Urology. 2013;64(6):873-875. https://doi.org/10.1016/j.eururo.2013.06.037

17: Ji S. Regenerate: Unlocking Your Body's Radical Resilience through the New Biology. Carlsbad, CA: Hay House; 2020. https://www.amazon.com/Regenerate-Biological-Reverse-Chronic-Disease/dp/1401956386

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