Re: Diagnosing prostate cancer at a curable stage means providing PSA tests to asymptomatic patients. Being a urologist is one of conflict of interest in discussing PSA screening - The BMJ

Dear Editor

I don't think the problem with PSA screening that Bradley and colleagues' pointed out is outdated. Rather, the advances in UK clinical practice and national screening programs of the European Commission mentioned by the authors are not based on the clear evidence that the benefits outweigh the harms. The interpretation is an error caused by not recognizing the difference between screening and diagnostic tests and misunderstanding overdiagnosis. (1) The various clinal markers, risk stratification models and MRI are used as ancillary tests for PSA. These are expected to improve sensitivity, specificity of PSA, or reduce unnecessary biopsies. It has nothing to do with solving the problem of PSA screening, overdiagnosis. Furthermore, since prostate cancer occurs in the elderly and the effects of death from other causes are significant, the endpoint should be OS, cancer specific survival (CSS) is not appropriate. Even with CSS benefits, without OS benefits, screening programs are meaningless. (2)

The advice by United States Preventive Services Task Force (USPSTF) in 2012 is fair and impartial. Not Disastrous. The essence of the problem of overdiagnosis is that the OS does not change as the screening rate decreases and the proportion of advanced cases increases. (3,4) The USPSTF statement was revised in 2018, but has not changed substantially. It just apparently changed the recommended grade and left the decision to the patient and the family doctor. As a result of balanced counseling, PSA tests are declining. Urologists rather do not give patients balanced information. (5)

The authors state that diagnosing prostate cancer at an early, curable stage means providing PSA tests to asymptomatic men. However, the pathological diagnostic criteria for prostate cancer emerged from "the Bowery series", an unethical medical practice. It is a morphological hypothesis created by a pathologist, has no scientific validity, and has not been verified even now. (6-8) Due to a tremendous amount of reports on the Gleason score, it is easy to misunderstand that the pathological diagnosis of prostatic cancer has been established. However, the criteria for diagnosing cancer and the grading as a prognostic factor after the diagnosis is made are completely different. No one knows about natural history of so-called "early prostate cancer". The first article in which the pathological criteria appeared included a dialogue between Hudson, the conductor of "the Bowery series", and Stout, a pathologist. (7) They shift responsibility to each other, recognizing that the criteria is not scientifically valid. Rather than overdiagnosis, it should be described that the misdiagnosis committed by Perry Hudson in the 1950s was overlooked until 70 years later and remained uncorrected. In fact, diagnostic prostate cancer at an early, curable stage is not possible with current pathological examinations.

Unfortunately, urologists promote PSA screening not for academic or scientific reasons. Being a urologist is one of conflict of interest in discussing PSA screening. I can understand that because I have been a urologist for 30 years.

1. Takahashi T. Would You Play a Russian Roulette-type Game of Prostate-specific Antigen Screening on Yourself? Eur Urol. 2022 Jan;81(1):e22. doi: 10.1016/j.eururo.2021.10.003.
2. Terret C, Castel-Kremer E, Albrand G, Droz JP. Effects of comorbidity on screening and early diagnosis of cancer in elderly people. Lancet Oncol. 2009 Jan;10(1):80-7. doi: 10.1016/S1470-2045(08)70336-X.
3. Takahashi TF. The golden rule: Do not do to others what you do not want done to yourself. Cancer. 2020 May 15;126(10):2319-2320. doi: 10.1002/cncr.32760.
4. Takahashi T. PSA Screening: a Kind of Russian Roulette? J Gen Intern Med. 2021 Sep;36(9):2853. doi: 10.1007/s11606-021-06989-x.
5. Koh ES, Lee AYJ, Ehdaie B, Marti JL. Comparison of US Cancer Center Recommendations for Prostate Cancer Screening With Evidence-Based Guidelines. JAMA Intern Med. 2022 May 1;182(5):555-556. doi: 10.1001/jamainternmed.2022.0091.
6. Young RH, Eble JN. The history of urologic pathology: an overview. Histopathology. 2019;74(1):184-212.
7. Totten RS. Some experiences with latent carcinoma of the prostate. Bull N Y Acad Med. 1953;29(7):579-82.
8. Aronowitz R. "Screening" for prostate cancer in New York's skid row: history and implications. Am J Public Health. 2014;104(1):70-6.