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Editorial Comment to Prostate‐specific antigen screening impacts on biochemical recurrence in patients with clinically localized prostate cancer

In this issue of the International Journal of Urology, Hashimoto et al. examined the impact of prostate-specific antigen (PSA) screening in patients with clinically localized prostate cancer undergoing robot-assisted radical prostatectomy. They hypothesized that the lower rate of PSA screening in Japan led to poorer prognosis after radical prostatectomy in previous Japanese cohorts, and showed that patients diagnosed based on a PSA screening test tended to have cancers in an early phase. A previous hospital-based cohort study reported that 73.5% of patients aged 55–69 years were identified by PSA testing, and these patients had a better prognosis than those diagnosed with local and/or systemic symptoms, and a similar result was obtained from another Japanese population screening cohort study, in which the prognosis of prostate cancer patients detected by population screening was shown to be more favorable than that for those diagnosed outside of population screening. These findings reflected earlier detection of prostate cancer using PSA testing in all stages of prostate cancer; however, the present study showed that pathological features of cancer and biochemical recurrence-free survival were more favorable in patients identified through PSA screening than patients who underwent PSA testing at a urology clinic for clinically localized prostate cancer. As described, higher age, PSA levels and prostate volume possibly lead to poorer clinical outcomes. The interesting issue of PSA screening in patients not showing clinical symptoms being more important for detecting early prostate cancer than PSA testing in urological clinics could become a driving force to proceed population-based PSA screening in Japan. In contrast, the problem of overdiagnosis and overtreatment of prostate cancer might result from a favorable stage shift after the instigation of PSA screening. In the present study, the patients with 2012 PRIAS study criteria group were 12.4% in the PSA screening group, and the biochemical recurrence-free survival in these patients was very low. Further clinical studies are required to define optimal treatment, including active surveillance, for very low-risk patients detected by population-based PSA screening.