UroToday.com – Although the incidence and mortality of prostate cancer in Japan have increased, they are lower than in Western countries, including the USA. In 2005, there were 9,264 deaths from prostate cancer, accounting for 4.7% of the total number of cancer deaths in Japan. The previous Japanese guidelines published in 2001 did not recommend prostate cancer screening using PSA and DRE. However, population-based PSA screening has rapidly spread nationwide since the late 1980s.
New cancer screening modalities that lack sufficient evidence have attracted public interest and have been introduced by several local governments. In 2001, PSA screening was conducted in only 14.7% of local municipalities. After the news of the Emperor’s prostate cancer, PSA screening disseminated rapidly nationwide. At present, PSA screening is conducted in almost half of local municipalities.
In Japan, there are two major guidelines for prostate cancer screening: those of the Japanese Association of Urology and ours. Since the guidelines reached different conclusions, arguments concerning prostate cancer screening have continued. The Japanese Association of Urology recommended population-based prostate cancer screening for men aged 50 years and over. Although their guidelines development process and its conclusions are similar to those of the American Urological Association (AUA), their target groups are different. The AUA guidelines recommended prostate cancer screening at the individual level, not for population-based screening. Based on the balance of benefit and harms, evidence-based guidelines have not recommended prostate cancer screening at the community level. In any cases, most guidelines recommend shared decision-making based on appropriate information relating to the benefits and harms associated with screening.
To reduce cancer mortality, effective screening should be implemented properly. The introduction of prostate cancer screening at the community level in Japan is associated with several problems. First, compared with Western countries, the mortality of prostate cancer in Japanese men is around one-third. Between 1960 and 1998, the age-adjusted mortality increased from 1.4 to 5.4 per 100,000 in males, and it has flattened since 1999. Second, there is no opportunity to conduct shared decision making in population-based screening. In Japan, there are two major screening programs: population-based screening and opportunistic screening.
Population-based screening programs have been mainly conducted in local municipalities with government support. On the other hand, opportunistic screening depends on requests by individual members of the public or on the recommendation of their health advisors: this type of program is also common and is conducted in clinical settings using various modalities. In both programs, informed consent for cancer screening has been poorly developed. For participation in cancer screening programs, it is difficult to provide appropriate information regarding the benefits and harms. Therefore, we have developed the leaflets based on the cancer screening guidelines with public involvement. Lastly, even if the effect of screening were to be evaluated by large-scale RCTs, introduction of population-based screening in Japan would require an original study to assess its feasibility in Japan. Local evidence is required to make the decision about the introduction of cancer screening.
However, in Japan, no studies have evaluated mortality reduction from prostate cancer. Given racial differences, the results obtained from studies conducted in other countries should be used cautiously. After the release of the guidelines, original studies have been planned in Japan. Considering both the results of studies conducted in Japan and in other countries, prostate cancer screening should be reconsidered.
After the guideline was completed, intermediate RCT results were published. The results of the PLCO and ERSPC studies are big issues in Japan especially among urologists, who are interested in prostate cancer screening. In the guideline, we mentioned the possibility to revise recommendation based on the results of theses two studies. Therefore, we immediately announced our intention to review the results of both studies on our website (http://canscreen.ncc.go.jp/, Japanese language only). Following our review of the results of both RCTs, the guideline for prostate cancer screening will be revised in the near future.
Written by Chisato Hamashima, MD1 as part of Beyond the Abstract on UroToday.com
1. Cancer Screening Assessment and Management Division, Research Center for Cancer Prevention and Screening, National Cancer Center, Japan
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