One out of two men over the age of 40 undergoes a PSA assay to screen for prostate cancer. This test is not recommended by health authorities.
On paper, the debate is over. Detecting prostate cancer using a PSA assay is of no major interest. The health authorities themselves affirm it: the risk of over-treatment exceeds the benefits. And yet, more than three million men go through this stage when they do not present any risk factor or worrying sign. “To screen or not to screen”, that is the question, summarize the presidents of the National Cancer Institute (INCa) and Public Health France. Norbert Ifrah and François Bourdillon sign the editorial of a dedicated edition of Weekly Epidemiological Bulletin, published on November 15. A major theme emerges: screening for prostate cancer remains highly problematic in France.
Less aggressive cancers
A paradox is underlined by the editorial writers of this BEH: in countries where incidence has been increasing and mortality has been falling since the 1990s, this examination has developed. France dominates its neighbors by far. The practice is “almost generalized” according to the admission of Norbert Ifrah and François Bourdillon. In fact, between 2013 and 2015, 48% of men underwent a PSA test after age 40. One age group, in particular, is targeted; 90% of 65-79 year olds have taken a test.
The High Authority of Health (HAS) however decided in 2010 on this blood test. In systematic screening, this approach has no demonstrated impact. Opinion confirmed by various European authorities. They even ask to limit the repetition of these dosages after 75 years. A call that is obviously not heard by health professionals. The decline started remains much too slow, even if it has the merit of existing.
“A large proportion of diagnosed prostate cancers are not very aggressive”, underlines Olivier Rouvière, of the Hospices Civils de Lyon (Rhône) in the BEH. Over a 10-year period, mortality is very low – including among men under active surveillance. It consists of “postponing the time of treatment in patients with cancer deemed to be at low risk”, while allowing treatment in time if the cancer becomes more aggressive. But this method remains little used in France.
MRI as an alternative
Another approach is regularly used after a suspicious PSA assay: biopsy. Invasive, it remains much less frequent. 48,700 men underwent this intervention which aims to confirm the profile of the tumor. This represents 0.41% of the male population analyzed. Here too, a slight decline is beginning. But there too, it is too slow.
Currently, the examination is performed blind, endorectally, and focuses on one area of the prostate. This presents a double problem: aggressive tumours, located differently, are under-detected; indolent cancers are over-diagnosed.
Olivier Rouvière offers an alternative. An imaging method would optimize the use of biopsy, multiparametric MRI. Prostate cancer is “reputed to be poorly visible in imaging”, recognizes the head of interventional vascular radiology at the Edouard-Herriot hospital. But this technique is precise. It would therefore make it possible to guide the samples towards the area of concern… or to rule out people who suffer from indolent forms. “It seems logical to propose an mp-MRI at the start of active surveillance to ensure that the patient does not present with aggressive cancer”, concludes Olivier Rouvière. This presents an additional argument in favor of enhanced monitoring.
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