"Most urologists believe that screening is saving lives."

Urologist Joel B. Nelson, co-director of the Prostate and Urologic Cancer Center at the University of Pittsburgh Cancer Institute, said that conviction is upheld by a European study, published March 26 in the New England Journal of Medicine.

An Oct. 21 Journal of the American Medical Association report raising questions about the benefits of prostate cancer screening mentioned the ongoing European trial, which studied a core age group of 162,243 men between the ages of 55 and 69 years to measure the rate of death of prostate cancer. They were randomly assigned to two groups, one to be screened at an average of one to four years; the second, the control group, didn't get that screening. Over nine years, it was found that prostate cancer was found in 8.2 percent of the screening group and 4.8 percent in the control group.

Comparing the number of deaths in each group, the study found that screening reduced the rate of death from prostate cancer by 20 percent. That success, though, came by treating a high number of patients who would not be expected to die from the disease.

The study said out of every 1,410 men screened, "48 additional cases of prostate cancer would need to be treated to prevent one death from prostate cancer."

"It's quite clear evidence that screening saved lives," Dr. Nelson said, particularly because the European control group had a low rate of being screened before joining the study.

In contrast, a U.S. study, published in the same issue of NEJM, had a smaller group (76,693 men) followed for seven to 10 years. It found little difference in death rates between the screening and control groups.

Among the cautions of that study is that almost half of the participants were screened for prostate cancer at some point before or during the study. All had similar cancer treatment options, which improved over the years and that may have kept the death rate low for both groups. The findings support the advice that men 75 years old and up do not benefit from early detection.

Because patients who are treated for cancer that is not life-threatening suffer "clear harms," Dr. Barnett S. Kramer, associate director for disease prevention at the National Institutes of Health, said more helpful information may develop as the two trials continue their followup.

"Now, if a man decides to get screened, that's perfectly reasonable. If a man decides not to get screened, that is also reasonable."

Dr. Nelson agreed that a longer followup time may yield better information about the possible benefits of screening.

"This morning I operated on a man 50 years old. For him the real benefit will be at 80 or 90 years. … We're finding many cancers that are not life-threatening, but aggressive cancers are being caught."

Dr. Nelson wants men to get both the digital rectal exam and PSA test. He recommends that once a patient is diagnosed with prostate cancer he should consult with specialists who have a lot of expertise in treatment, particularly with surgical experience in prostate cancer.

"To date, nothing has emerged that is better than what we are doing," he said. Now, he said, the American Urological Association recommends screening for even younger men, at 40 years old -- and no screening for older men.

"Treating younger men is very meaningful," Dr. Nelson said. Men need to know what possible side effects of treatment are, but he added, "Men that are younger usually get over the side effects and have a lot more to gain."

Dr. Ralph J. Miller Jr., director of the Allegheny General Hospital Prostate Center, said many men want to know if they have prostate cancer and they should discuss the pros and cons of screening with their doctors.

"Looking at it from a population statistical standpoint, you can make powerful arguments that you don't have to do it," Dr. Miller said. "On the other hand, looking at it from the individual patient and individual doctor's perspective is another thing.

"For example, a 57-year-old, according to the MetLife actuary, will live to be about 84. In that length of time, even a relatively low-grade prostate cancer can develop. The message is be aware the screening is available and decide."

Citing national cancer statistics, Dr. Miller said prostate cancer deaths have gone down over the past 20 years. According to the National Cancer Institute's SEER database, 192,280 men will be diagnosed with prostate cancer in 2009 and 27,360 men will die of the disease this year. Most of them will be older: From 2002-2006 the median age of men who died from the disease was 80 years.

"In the meantime folks actually do survive. Right now, people who are proactive about their health are going to get [screenings] done … Those that aren't, won't."

He predicted, "With a good national health plan we might get more people in that proactive group," adding that he would like to see improved screening that would detect a problem before radiation and surgery are needed to cure it.

For now, Dr. Nelson said, it's hard for primary physicians to find time to talk about prostate cancer screening with their patients.

"In an ideal world we would have an hour … it's not an ideal world," he said, adding that if a man is screened for prostate cancer, he should be ready to consider cancer treatment options.

"On the other hand, I meet men with really bad cancers who are mad they didn't get the test," Dr. Nelson said. "It can come down on both sides of the issue.

"Many primary doctors are taking these reports and taking them to mean we don't need to screen. That's oversimplifying," he said, again citing the European study.

"There is a medical legal issue," Dr. Nelson said, explaining that doctors want to follow whatever the community standards of health care are -- to test or not to test -- to avoid being sued by a patient.

"There are clearly patients I have operated on that I wonder, have I really benefited this patient? But if you ask a patient, if they are told they have been cured of cancer …"

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