EURURO Vol. 72 No. 2

E41 320

Letter to the Editor
Re: Jim C. Hu, David M. Nanus, Art Sedrakyan. Increase in
Prostate Cancer Metastases at Radical Prostatectomy in
the United States. Eur Urol 2017;71:147–9
Controversies exist as to the real benefits of prostate-
specific antigen (PSA) screening, and some of the negative
aspects of screening have been described by several recent
studies. The study by Hu et al shows an increasing trend
of more aggressive prostate cancer (PCa) being detected by
radical prostatectomy (RP) pathology, and the authors
cautiously conclude that this phenomenon is due to the
decrease in PSA screening.
The authors’ opinion could be understandably persua-
sive, especially in light of increasingly negative perceptions
about PSA screening since the US Preventive Services Task
Force (USPSTF) recommendations in 2008. However, we feel
it is somewhat early to draw conclusions about the impact
of decreased screening on PCa-specific mortality, and other
possible reasons should also be discussed in detail. For
example, there is demonstrated wide variation in the choice
RP as a treatment modality, and it is greatly affected by
practice size and geographic location . In addition, there
are currently no clear criteria for RP or radiation therapy
assignment owing to a lack of relevant randomized
controlled trials, and surgeon preference could also be a
factor.
Other reasons for the shift to finding more aggressive
pathology on RP include increasing utilization of active
surveillance, as most recent studies have supported active
surveillance for low-grade and localized PCa Further-
more, patients with clinically high-risk PCa could have a
greater chance of receiving RP owing to the
widespread use of robotic RP and advanced anesthesia
support capabilities . In addition, as recent guidelines
do not support the use of androgen deprivation therapy
(ADT) in localized PCa, a decreasing trend for ADT use for
localized PCa could increase the number of RPs in high-risk
or older patients; CAPSURE, Surveillance, Epidemiology, and
End Results (SEER), and Veterans Affairs data show that RP
and radiation therapy still account for a great proportion of
the therapies in elderly PCa patients . A final
explanatory factor is the decrease in the number of new
PCa patients in younger age groups, such as those aged <65
yr, observed in SEER data. This is possibly because of the
change in population structure related to the aging society
phenomenon.
How should we then view PSA screening? The answer
lies in the most recent study that assessed the value of
prostate biopsy in PCa patients with a PSA level of <10 ng/
ml . The authors found that if the initial biopsy results
were negative for these patients, long-term PCa mortality
was in turn very low. PSA screening is very important;
however, frequent PSA screening or further evaluation of
these patients should be performed prudently.
Conflicts of interest: The authors have nothing to disclose.
Acknowledgments: This work was supported by the Soonchunhyang
University Research Fund, which played a role in preparation of the
manuscript.
References
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Jae Heon Kim a,b,*
Yash S. Khandwalaa,c
Benjamin I. Chunga
aDepartment of Urology, Stanford University Medical Center,
Stanford, CA, USA
ava ilable at
journal homepage:
DOI of original article: .
0302-2838/# 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.