Screening strategies: a clinical perspective

Prostate cancer is increasing in incidence, particularly because of the control of competing causes of death and the lengthening life span of western men. Screening and early detection initiatives among symptom free men show that the disease can be detected at earlier stages when hope for cure is reasonable. Prostate specific antigen is the most useful marker for prostate cancer. Analytical methods to improve its sensitivity and specificity include PSA density, age specific PSA reference ranges and PSA velocity or the rate of change in PSA. Older paradigms of the natural history of prostate cancer have been heavily influenced by characteristics of clinical disease. However, improved detection of the disease through better diagnostic tools and heightened public awareness may be changing the dynamics of the disease. The prevalence of advanced disease is falling, and more knowledge is accumulating on the identification of clinically significant disease. The most appropriate definition of clinically significant disease today must be based on a new paradigm, one that can build on but not be bound by older models.