In Reply: I am grateful that Mr. Kurator and Dr. Jenkins took the time to read my commentary and to respond to it. The debate about prostate cancer screening remains fraught, and passions run high on both sides. Like screening for breast cancer, colon cancer, and cervical cancer, screening for prostate cancer has never been shown to have an impact on all-cause mortality in a randomized controlled trial. Some critics of cancer screening argue that without an overall survival benefit, screening should not be recommended. (It is worth noting that colon cancer and cervical cancer screening can detect precancerous lesions and thus have the additional benefit of reducing the risk of needing more aggressive surgery.) The critics’ argument, then, is that it is not enough to reduce your risk of dying of prostate cancer or breast cancer: screening should result in your living longer. The challenge is that any individual disease represents a very small fraction of all-cause mortality, and the disease-specific mortality benefit is thus lost in the noise. There is also the legitimate concern that screening may be increasing other causes of mortality and thus simply exchanging one cause of death for another. There is no space to rehash this argument here, but the disagreement about end points for cancer screening trials persists.
Whether the admittedly modest benefit of prostate cancer screening is worth the harms cannot be answered without including the patient in the discussion: the value placed on the different benefits and harms will vary from man to man. There are experts who are in favor of screening and experts who are opposed to screening, and it would be paternalistic to let patients hear only one side of the debate, hence the role of shared decision-making. It is also important for patients and clinicians to know that prostate cancer screening is evolving, and the decision-makng about whom to biopsy and whom to treat has become more nuanced. The hope is that this will increase the benefits and decrease the harms, but that remains to be proven. In the meantime, each of us men needs to decide whether we will choose to be tested. I won’t choose for you if you don’t choose for me.
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