the danger of extending them to healthy men

90% of tumors are detected in early stages and are mainly curable through radiotherapy. In the other 10%, which are diagnosed in advanced stages (such as when metastases occur and the tumor moves to other areas), survival has tripled in the last 15 years thanks to the treatments that have been appearing.

In this way, there are many men in Spain who carry the label of this cancer, which has its World Day on June 11. According to data from the Spanish Society of Medical Oncology (SEOM), more than 100,000 men live with the tumor.

Survival – five years after diagnosis – is 89.8%, the highest among common tumors: it has been growing since the 90s. Despite these figures, in 2022 5,962 people died due to this tumor.

“In recent years there has been a decrease in mortality figures,” he explains to EL ESPAÑOL. Rebecca Lozanoscientific secretary of the SEOM and oncologist at the Salamanca University Care Complex.

This decrease has been, “probably, associated with improvements in treatments, both in localized prostate cancer—fortunately in the majority of cases—where both surgery and radiotherapy have improved, but also in metastatic disease. This translates into a better prognosis.”

The number of cases of prostate cancer has increased significantly in recent decades. During the 70s and 80s, growth was 1.3% annually, but since the 90s it has shot up to around 7%.

It is usually a slow-growing tumor and was traditionally diagnosed in those over 65 years of age, but The incidence in minors of that age has been growing by 14.6% annually in recent times.

The main responsible for this increase is called PSA. These letters correspond to the so-called prostate-specific antigen, a protein that is detected in the blood of men with prostate cancer.

This protein was discovered in the 1970s and since the late 1980s it was seen as an opportunity to detect hidden cancers in men of a certain age through a blood test, confirming the diagnosis with a biopsy—the removal of a sample of tissue to verify that it is carcinogenic— later.

Urinary incontinence or impotence

The problem is that PSA is not exclusive to cancer cells. Elevated levels of this protein can be found in benign prostatic hyperplasia, prostatitis, acute urinary retention or after a prostate massage.

Therefore, although it is a good test to diagnose cancer early when a man goes to his doctor’s office, its use to detect tumors in the healthy population is more controversial.

The idea is simple: just as mammograms and detection of fecal occult blood can detect breast and colorectal cancers in people without symptoms, PSA could do the same for the prostate. Detecting cancer in its earliest stages allows it to be treated earlier and have a better prognosis.

This, however, has a problem. Many of the cancers detected by the test would not have caused any problems for the patient: As it is a slowly developing tumor, the person would not see their life affected by it.

And in the early stages it is not possible to know which tumors will end up causing health problems and which will not.

At best, gratuitously generated inconveniences are unnecessary biopsies and the anxiety of being labeled with the word cancer.

In the worst case, this diagnosis can lead to unnecessary treatments, with potential side effects, including impotence and urinary incontinence.

“The issue of screening is very controversial,” explains Dr. Lozano. “It has always been and continues to be. The main problem is overdiagnosis: in some studies it has been seen that there may be an overdiagnosis of indolent tumors, which were not going to show their face and that the person was not going to have problems derived from that tumor but would die due to age and other conditions.

“This, in the end, results in unnecessary treatments,” he continues, “with implications for the patient, such as side effects of the treatments, but also even for the national health system itself, because Carrying out these treatments involves an expense, a cost, and that is why the guidelines have been increasingly restrictive.“.

In Spain, the Public Health Commission – made up of representatives of the Ministry of Health and the autonomous communities – rejected in 2019 including this screening in the common portfolio of services: the risks outweighed the possible benefits.

However, in 2022, the Council of Europe recommended that European Union member states consider expanding their screening portfolio to, among others, prostate cancer.

For this reason, in 2024, Health commissioned the Network of Health Technology Assessment Agencies to carry out a new update report on prostate cancer screening.

“An effort is being made to ensure that other types of cancer, apart from breast, cervical and colorectal cancer, are included in more organized programs,” recalls Lozano. “The European program has said that pilot programs must be implemented in men up to 70 years old, but in Spain they are not yet established.”

Lozano points out that studies on the subject have given somewhat contradictory results. And it is that The two large clinical trials carried out to observe the feasibility of screening yield inconclusive results.

The first of them was carried out in the US between 1993 and 2001 and more than 75,000 men between 55 and 74 years old participated. An annual PSA test and a digital rectal examination were performed for the first four years.

Subsequent analyzes observed a 12% increase in tumors without avoiding any deaths and a fairly high proportion of false positives (12%-13% after several rounds of screening).

Improve screening

The other study, carried out in Europe with more than 180,000 asymptomatic men, showed positive but not entirely conclusive results. By performing a PSA every four years, a reduction in mortality of around 21% was achieved, avoiding one death from cancer in every 1,055.

However, an excess of diagnoses of 63% and an overdiagnosis of 50% were observed. The benefit of screening was only seen in men between 55 and 69 years old.

Despite everything, Dr. Lozano believes that prostate cancer screening will end up taking over. “It is a tumor that has a very high prevalence; therefore, the effort has to be in finding how to improve it.”

The European plan establishes the use of PSA but also a confirmatory MRI as a prior step to the biopsy, but other options are being addressed, such as “multiparametric MRI or the use of more specific biomarkers, which combine not only the PSA but also other parameters “.

In fact, in the future the risk of prostate cancer may end up being determined in saliva. A British study that has been presented at the annual meeting of the American Society of Clinical Oncology (ASCO) has evaluated the effectiveness of taking saliva samples and analyze DNA for 130 genetic variations in more than 6,000 men between 55 and 69 years old.

The results, which must be confirmed in studies with large population groups, indicate that this new test gave fewer false positives than the PSA test, but also fewer false negatives, and also accurately detected cancers missed by MRI.

“I insist that it is a very prevalent tumor, with a high incidence, but we will have to focus more on improving this screening,” concludes Lozano.