Prostate cancer screening: waiting for Godot

The issue of prostate cancer screening continues to go around and around. All agree that a randomized clinical trial is needed to determine whether screening does more good than harm. However, everyone also agrees that the absence of evidence of benefits is not proof that benefits are absent. That prostate cancer is a significant health problem is undeniable. For Canadian men it is now the most commonly diagnosed malignant disease and is second only to lung cancer as a cause of cancer-related death.1 The burden of this condition and the lack of definitive answers mean that there is not only an opportunity to provide further information short of a randomized controlled trial, but also a risk in doing so because the prostate cancer world is divided into 2 camps on the issue of screening: evangelists and snails.2 The lack of definitive information has not been a barrier to thought on this matter. A search of the CANCERLIT database using the terms "prostate neoplasms" and "mass screening" revealed only 56 articles from 1983 to 1989, but 265 articles or comments from 1990 to 1994 and 362 from 1995 to May 1998. Current screening studies for prostate cancer may not be perfect, and with the advent of newer methods for classifying patient risk and for testing, their results may not be relevant in 10 years when they mature. It is hoped that levels of certainty about what works, and for whom, will improve dramatically. The required knowledge can be developed only with the proper research support, a fact noted by the near-universal recommendation of the National Prostate Cancer Forum in February 1997.16 To date, the response to this recommendation from all levels of government has been a deafening silence. The only way we will stop waiting for Godot is to determine what is effective and what is not. Given the current burden of this disease and the increase that is looming as baby-boomers enter the age group in which incidence rates of prostate cancer rise steeply, the time to find answers is now. In the meantime, the best we can do is be honest with our patients about what we know and what we don't know regarding prostate cancer screening.16-18 11. Lu-Yao GL, Yao SL. Population-based study of long-term survival in patients with clinically localized prostate cancer. Lancet 1997;349:906-10. 12. Smith DS, Catalona WJ, Herschman JD. Longitudinal screening for prostate cancer with prostate-specific antigen. AMA 1996;276:1309-15. 13. Helgesen F, Holmberg L, Johansson JE, Be