Antigene prostatico specifico, screening del cancro della prostata, linee guida e il giudice saggio

AUTORI

ABSTRACT

PSA, prostate cancer screening, clinical practice guidelines and the “wise judge”

PSA, prostate cancer screening, clinical practice guidelines and the “wise judge”. PSA appeared since its earliest clinical use to be a promising tool for the early detection of prostate cancer (PCa) and several studies investigated its effectiveness in the screening of asymptomatic men. Three large randomized controlled trials involving 654,293 men, performed over the last 25 years, have been completed and results are now available. Two trials showed that PSA screening lead to an estimate of approximately 1 prostate cancer death avoided every 1000 men screened. The third, more recent, trial did not show any significant effect on PCa mortality after a 10 year follow-up. PSA screening also led to a risk reduction of 3 metastatic cases per 1000 screened men, but these findings did not reflect in a reduction of PCa specific mortality. The three studies confirmed a very high rate (50%) of overdiagnosis of indolent cancers, that increased the frequency of biopsy related complications and side effects due to treatments (incontinence, impotence, bowel dysfunction). In summary, benefits of PSA based screening of PCa are still debated while harms are established. A systematic search for clinical practice guidelines (CPG) published over prior 5 years identified 12 pertinent documents. CPGs unanimously agreed in recommending against PSA-based mass screening for PCa as a public health policy. Conversely, positions of CPGs are mixed concerning PSA for opportunistic screening: some CPGs recommend against, others recommend that an individualized risk-adapted strategy for early detection should be offered to well informed men with good performance status and 10-15 years of life expectancy. The comparative synopsis of CPGs shows the variability of decision-making in relation to the clinical problem and/or the context and offers to the physician the opportunity to “wisely” discuss with the patients all the possible choices supported by evidence.

BIBLIOGRAFIA