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The Accurate Screening of Prostate Cancer in Europe

Submitted by on 06 Oct 2011 – 11:01

The Accuarte Screening of Prostate Cancer in Europe Chris H Bangma, MD PhD, Chairman of Urology, Erasmus Medical University Centre, Rotterdam, The Netherlands

The dramatic growth in scientific research focused prostate cancer continues to challenge health professionals and public health authorities worldwide. Recent publications concerning the efficacy of prostate cancer screening have fuelled public debate concerning appropriate testing policies. Improvements in health care and an aging population in the EU suggest that the management of prostate cancer will pose increasing demands on the already strained health care systems.

Ideally a common European strategy concerning prostate cancer screening should be developed. Barring specific recommendations this strategy should focus on providing accurate information on the efficacy and effectiveness of prostate cancer screening as well as providing equal access and quality of care to those men who seek treatment for this disease as suggested by the 2009 manifest of Europa Uomo (, the umbrella organization of patient representatives for prostate cancer. However, the European Randomized Study of Screening for Prostate Cancer (ERSPC) demonstrated some geographic variations in the incidence and mortality of this disease, showing the highest incidence and mortality in the North of Europe in contrast with regions in the south of Europe (also: Globocan). These differences might be attributed to both environmental factors such as dietary habits, life style and sun exposure and genetic factors including both racial and familial traits, but also to the intensity of testing.

The 2009 publication of the ERSPC showed that population based screening of men aged 55-75 years can reduce prostate cancer mortality by at least 21%.To date, no country has embraced population based testing because the target population remains undefined and the relative benefits and harms associated with screening continue to be debated. In Scandinavia, Sweden has pursued regional screening studies designed to optimize screening protocols, while Norway and Denmark discourage population based testing. In The Netherlands, discussion has focused on the possible inclusion of new imaging tools and risk based protocols, while in Belgium health authorities have asked health professionals to compose a “balanced guideline”. The United Kingdom awaits the results of the ProtecT trial expected in 2015 before making any further revisions to its policies, while France and Germany support individual patient testing.

Review of the current medical literature surrounding prostate cancer screening has resulted in an international opinion paper on population based and individual screening (presented at the SIU Berlin, October 18th 2011). Our understanding of the incidence and natural history of this disease has grown substantially during the past decade especially based on EU research, and has altered our perspective concerning how to conduct population based screening. We realize that serial PSA testing may lead to a decline in prostate cancer mortality but can also lead to the diagnosis of and treatment of large number of indolent tumours (23-50% of detected cancers). Population screening will produce a large benefit in survival and quality of life in a few men diagnosed and treated, but will also cause a large number of men to know that they are having a cancer for many more years of their life.

The best age to start screening is unknown, and might be dependent on risk factors like family history or genetic factors. Also the optimal interval for repeated screening still has to be determined. From a public health perspective, the associated morbidity may or may not be balanced by net health care benefits. To date, prostate cancer screening has yet to satisfy public health criteria for population based testing, leading many researchers to explore the efficacy of individual risk assessment for early detection of this disease. Risk assessment instruments combined with information on prostate cancer provide mechanisms to avoid unnecessary prostate biopsies, and to reduce the potential for overtreatment in men with low risk for prostate cancer. European based validation studies are however required and should preferably have a central data centre with expertise in data management and data analyses.

Therefore it is recommended that the current studies on screening are continued, as data on longer follow-up will provide greater insight on risk classifications for metastatic disease and cancer specific mortality, as well as on interval cancers and screening intervals. Future mass screening protocols should incorporate personalized screening protocols and risk assessment tools that have been developed in Europe (,, and include parameters like imaging and novel serum/urine markers to reduce overdiagnosis and subsequent overtreatment.

Information on prostate cancer screening and treatment needs to be balanced and to address the regional situation.