Screening for melanoma and options for its evaluation [see comment

A review of the published evidence presented here argues that screening for melanoma is recommended and practised at present, but with wide diversity of opinions about its value; there is evidence that screening has considerable potential for benefit, but the evidence of actual benefit is limited; and there are substantial costs and potential hazards from screening. On this basis the evaluation of screening procedures for melanoma is important, and options for this are discussed. The ideal study design to assess the efficacy of melanoma screening in reducing mortality is a large scale randomised trial. This may need a well coordinated proposal involving several centres in one or more countries, and the cost would be substantial. Without such a trial, however, it is most likely that increasing resources will be put into poorly designed screening programmes of unknown value. The simplest and strongest designs use individual randomisation, but group randomisation designs may have practical advantages, though they require a greater sample size. Designs based on general population screening, and on screening only high risk groups, are both considered. They answer different questions. In countries with high incidence the value of general population screening is probably the more critical. Not enough is known to specify the type and frequency of screening precisely; both screening by doctors and self screening require evaluation, and annual screening should probably be tested. The age range at risk will depend on the local incidence, but is likely to be quite wide-for example, 45-69, and both sexes need inclusion. Thus a suggested design for a moderate to high incidence area would be a trial, randomised by individual or group, assessing at least two annual rounds of both screening by doctor and self screening (ideally by a factorial design), for adults aged 45-69, with mortality over several years' follow up as the critical outcome. In an area with good data systems such a study could compare screening offered to some 260,000 subjects with 10 times that number of controls passively followed up, with 90% power to detect a one third reduction in mortality. A general assessment of costs over five years gave estimates of $8.3 million for the screening programme and $2.4 million for the evaluation. The much weaker designs, area based cohort studies using individual data or a simpler ecological comparison, and case-control studies, are also considered. If well designed with attention to their methodological limitations they may be valuable but are unlikely to be as definitive as a randomised trial.     

Role and evaluation of mammography and other imaging methods for breast cancer detection, diagnosis, and staging

Mammographic screening of women age 40 and older can reduce breast cancer deaths by at least 30% to 40%. However, not all cancers are detected by mammography. Although a new supplementary modality for screening could, in theory, fill in this detection gap, such utilization must be based on rigorous demonstration of its ability to consistently and frequently find early cancers missed by mammography, such as those occurring in dense breasts or rapidly growing interval cancers that surface clinically between mammographic screens. After an abnormality is found at mammographic screening, supplementary mammographic views and/or ultrasound are now used to match the finding with an ACR BIRADS final diagnostic assessment category to indicate the relative likelihood of a normal, benign, or malignant diagnosis so that routine screening, short interval follow-up, or biopsy can then be advised. Appropriate categorization will maximize early cancer detection and minimize false-positive biopsies. Application of a new imaging method to this type of diagnostic evaluation requires well-designed studies to determine its effectiveness for this purpose.     

Potential contribution of screening to cancer mortality reduction

The objective of screening for cancer is to reduce mortality or to improve quality of life. Screening is practiced for several anatomical sites and by several tests. Only cervical cancer screening based on cytological smears has been shown to be effective as a public health policy. Screening for breast cancer based on mammography was shown to reduce mortality in several randomized trials and nonexperimental studies. However, no data are available on its effectiveness at population levels in terms of a public health policy. There are several other valid tests. Application of these tests has failed to demonstrate a reduction in mortality or such an application was never tried and tested. This emphasizes that the prerequisite for effective screening is that the total program is valid and not only the test. At present, knowledge on screening is not fully applied in most European countries. Regular screening for cervical cancer will result in a 90% reduction in the risk of invasive disease. It is likely that the protective effect for breast cancer is about 30%. At the population level, smaller protections are to be expected, and well-organized screening programs are likely to reduce the total cancer death rate by 6 to 10% among females.     

Prenatal screening for cystic fibrosis carriers: an economic evaluation

The cloning of the CFTR gene has made it technically possible to avert the unwanted birth of a child with cystic fibrosis (CF). Several large trials offering prenatal CF carrier screening suggest that such screening is practical and that identified carriers generally use the information obtained. Therefore, a critical question is whether the cost of such screening is justified. Decision analysis was performed that used information about choices that pregnant women were observed to make at each stage in the Rochester prenatal carrier-screening trial. The cost of screening per CF birth voluntarily averted was estimated to be $1,320,000-$1,400,000. However, the lifetime medical cost of the care of a CF child in today's dollars was estimated to be slightly>$1,000,000. Therefore, despite both the high cost of carrier testing and the relative infrequency of CF conceptions in the general population, the averted medical-care cost resulting from choices freely made are estimated to offset approximately 74%-78% of the costs of a screening program. At present, if it is assumed that a pregnancy terminated because of CF is replaced, the marginal cost for prenatal CF carrier screening is estimated to be $8,290 per quality-adjusted life-year. This value compares favorably with that of many accepted medical services. The cost of prenatal CF carrier screening could fall to equal the averted costs of CF patient care if the cost of carrier testing were to fall to $100.     

Judaism, genetic screening and genetic therapy

Genetic screening, gene therapy and other applications of genetic engineering are permissible in Judaism when used for the treatment, cure, or prevention of disease. Such genetic manipulation is not considered to be a violation of God's natural law, but a legitimate implementation of the biblical mandate to heal. If Tay-Sachs disease, diabetes, hemophilia, cystic fibrosis, Huntington's disease or other genetic diseases can be cured or prevented by "gene surgery," then it is certainly permitted in Jewish law. Genetic premarital screening is encouraged in Judaism for the purpose of discouraging at-risk marriages for a fatal illness such as Tay-Sachs disease. Neonatal screening for treatable conditions such as phenylketonuria is certainly desirable and perhaps required in Jewish law. Preimplantation screening and the implantation of only "healthy" zygotes into the mother's womb to prevent the birth of an affected child are probably sanctioned in Jewish law. Whether or not these assisted reproduction techniques may be used to choose the sex of one's offspring, to prevent the birth of a child with a sex-linked disease such as hemophilia, has not yet been ruled on by modern rabbinic decisions. Prenatal screening with the specific intent of aborting an affected fetus is not allowed according to most rabbinic authorities, although a minority view permits it "for great need." Not to have children if both parents are carriers of genetic diseases such as Tay-Sachs is not a Jewish option. Preimplantation screening is preferable. All screening test results must remain confidential. Judaism does not permit the alteration or manipulation of physical traits and characteristics such as height, eye and hair color, facial features and the like, when such change provides no useful benefit to mankind. On the other hand, it is permissible to clone organisms and microorganisms to facilitate the production of insulin, growth hormone, and other agents intended to benefit mankind and to cure and treat diseases.     

Effectiveness of screening for osteoporosis by bone density measurement for the prevention of fractures: a review of the evidence]

To review evidence on the benefits of screening women and men for osteoporosis, a Pub Med search was performed in English papers published between 1990 and 2002. We used data from a cohort study to estimate risk of fracture from bone mineral density. Bone mineral density measured by dual X-ray absorptiometry (DXA) can predict bone fracture among elderly women, peri- and early post-menopausal women, and elderly men. It is recommended that all white women older than 65 years be screened routinely for osteoporosis. We suggest that Japanese elderly women should receive BMD measurements as a screening, but we have still issues to be solved including age from when the screening should be started, methods, and how to treat the women found to have osteoporosis at the screening. For peri- and postmenopausal women and elderly men, it might be beneficial to measure BMD as a screening and start treatment for those patients found to have osteoporosis. However, incidence of fractures for these people is lower than that for elderly women. One bone mass measurement can predict bone fracture risk for as long as over 10 years or more, but predictive ability of BMD decreases with time. Therefore, cost effectiveness needs to be reviewed to determine the benefits of screening among peri-menopausal women and men. Although bone assessment by quantitative ultra sound (QUS) method by ultrasound can also predict future fractures, only a relatively small number of longitudinal studies have been conducted in the Western countries, and there is no established evidence by means of longitudinal studies among Japanese. It is necessary in Japan to seek such evidence, however, since this method is widely used for an osteoporosis examinations.     

Factors determining acceptability of mammography in an Asian population: a study among women in Singapore

Population-based mammographic screening has been shown to be effective in reducing breast cancer mortality in the West. In Singapore, a project carried out to determine the effectiveness of implementing such a program locally invited 28,000 women between the ages of 50 and 64 years for mammography. The current study, which was part of this larger project, was intended to determine factors contributing to the acceptance of mammographic screening among women in Singapore. A questionnaire was administered in-person to 300 attenders and 260 non-attenders. The respondents were compared with respect to basic demographic characteristics, previous preventive behavior, informal social support, and attitudes towards early detection. We found that screening attenders were more likely to be Chinese than Malays (14 percent of the population) or Indians (seven percent), and to be working outside the home (adjusted odds ratio [OR]) = 4.5, 95 percent confidence interval [CI] = 2.6-7.9). A greater proportion of attenders had a history of other screening tests such as the Pap smear (OR = 4.7, CI = 2.6-8.7 for recent smear compared with never having had a smear). They were also more likely to indicate a sense of personal susceptibility to cancer, but did not differ from non-attenders in terms of believing in cancer prevention, or of preferring to be told if they did have cancer. The strongest independent predictor of attendance, however, was encouragement by her spouse or family member. For women in this population to be persuaded effectively to participate in mammographic screening, it would be important to convince family members of the benefits of the test. At the same time, education targeted specifically at women of the appropriate age group should address the issue of the personal relevance of screening for breast cancer.     

Design of fast enzymes by optimizing interaction potential in active site

The diffusional encounter between substrate and enzyme, and hence catalytic efficiency, can be enhanced by mutating charged residues on the surface of the enzyme. In this paper we present a simple method for screening such mutations. This is based on our earlier result that electrostatic enhancement of the enzyme-substrate binding rate constant can be accounted for just by the interaction potential within the active site. Assuming that catalytic and structural integrity is maintained, the catalytic efficiency can be optimized by surface charge mutations which lead to stronger interaction potential within the active site. Application of the screening method on superoxide dismutase shows that only charge mutations close to the active site will have practical effect on the catalytic efficiency. This rationalizes a large number of findings obtained in previous simulation and experimental studies.     

Current methods for assessing mucociliary transport disorders in the diagnosis of chronic rhinosinusitis]

This paper summarises the findings of a systematic review of research on preschool vision screening. The review concludes that the provision of such screening programmes should be reconsidered, if not abandoned.     

The relationship between health gain and effort in mass screening for breast cancer

Mass screening for breast cancer reduces the mortality of this disease. In the Netherlands, with a very high incidence of breast cancer, a well organized health care system and a stable economic prosperity, the decision taken to implement nationwide breast cancer screening for the female population aged 50-70 years appears well-founded. The first data indeed suggest a reduction of breast cancer in the coming years. The effects of screening as such will be difficult to evaluate since the programme leads also to optimalization of breast cancer treatment in general. Other factors, such as adjuvant therapy, may have a beneficial effect on breast cancer mortality, reducing the yield of the screening proper. This and the non-negligible negative aspects should not be hidden from the public. Continuous evaluation and quality control, not only in mammography techniques and reading, but also in the treatment of the detected cases, are essential for a successful screening programme.     

Differences in detection of alcohol use in a prenatal population (on a Northern Plains Indian Reservation) using various methods of ascertainment

Although Fetal Alcohol Syndrome (FAS) rates have been reported to be higher in American Indian populations, no screening tool has been validated for alcohol use in American Indian women. The objectives of this study were to compare the detection of prenatal alcohol use by a self-administered questionnaire to detection by clinical interview; and to ascertain whether the screening tool would increase detection of pregnant women who are abusing alcohol. The hospital records of the women were reviewed for any history of alcohol-related illnesses or injuries to compare with results obtained from the questionnaire. Seventy women attending their first prenatal clinic visit on a reservation were screened for alcohol use. There was a wide range in detection of prenatal alcohol use (20%-71% of the sample detected) depending on the method used. There was a large variation in sensitivities (7%-93%) of the individual questions in identifying patients detected as "high risk" by the clinicians. The T-ACE screening questions significantly increased detection of alcohol use compared to detection by the clinicians (p = 0.04 Fisher's exact test). Due to the large variation between different methods of detection, it is recommended that screening tools that increase detection of alcohol use should be combined with methods of higher specificity such as using questions about quantity and frequency of alcohol intake, medical chart review and clinical interview. We also found that various interpretations of the screening questions by the patients highlighted the need to tailor the wording of individual questions to the particular patient population.     

Preschool vision screening: rationale, methodology and outcome

Although population outcome studies support the utility of preschool screening for reducing the prevalence of amblyopia, fundamental questions remain about how best to do such screening. Infant photoscreening to detect refractive risk factors prior to onset of esotropia and amblyopia seems promising, but our current understanding of the natural history of these conditions is limited, thus limiting the prophylactic potential of early screening. Screening for strabismic, refractive and ocular disease conditions directly associated with amblyopia is more clearly proven, but the diversity of equipment, methods and subject populations studied make it difficult to draw precise summary conclusions at this point about the efficacy of photoscreening. Sensory-based testing of preschool-age children exhibits a similar combination of promise and limitations. The visual acuity tests most widely used for this purpose are prone to problems of testability and false negatives. Moreover, the utility of random-dot stereograms has been confused by misapplication, and new small-target binocularity tests, while attractive, are as yet inadequately field-proven. The evaluation standard for any screening modality is treatment outcome. However, variables in amblyopia classification and quantitative definition differences, timing of presentation, nonequivalent treatment comparisons, and compliance variability have been uncontrolled in virtually all extant studies of amblyopia treatment outcome, making it difficult or impossible to evaluate either the relative efficacy of different treatment regimens for amblyopia or the effects of age on treatment outcome within the preschool age range. The latter issue is a central one, since existence of such an age effect is the primary rationale for screening at younger rather than older preschool ages. The relatively low prevalence of amblyopia makes it difficult to achieve a high screening yield in terms of predictive value, but functionally increasing prevalence by selective screening of high risk populations causes further problems. Unless a "supertest" can be devised, with very high sensitivity and specificity, health policy decisions will be required to determine which of these two characteristics should be emphasized in screening programs. Performance of screening tests can be optimized, however, with adequate training, perhaps via instructional videotapes.     

Perceived social support predicts outcomes following myocardial infarction: A call for screening?

Comments on an article by H. S. Lett et al (see record 2007-09406-005), which reported that patients in the Enhancing Recovery in Coronary Heart Disease (ENRICHD) trial with elevated symptoms of depression or with lower perceived social support without elevated depressive symptoms were at increased risk for death or nonfatal reinfarction. Lett et al recommended screening '...for multiple dimensions of perceived functional support and depression in order to identify those at increased psychosocial risk who may benefit from treatment." They provided a careful and thoughtful analysis of the differential importance of specific domains of social support following acute myocardial infarction (AMI). Their broad call for screening, however, does not appear to be justified. B. D. Thombs suggests that, rather than a nonspecific recommendation for screening of psychosocial risk factors, a more reasonable approach given current knowledge in cardiovascular care settings would be to recommend screening for depression when competent diagnosis, treatment, and follow-up services can be arranged and to emphasize the need for research that attends to important, but generally neglected, elements of the screening process, such as when, where, and how often to screen patients and how to integrate accurate screening methods with effective treatment and follow-up services. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cancer of the prostate. 3: Men's healthcare needs

This article, the third in a three-part series, addresses the complex issues surrounding screening for prostate cancer. The purpose of screening in health care is discussed and the advantages and disadvantages of the various screening tests for the early detection of prostate cancer are outlined. The use of one specific technique to screen men for prostate cancer is questioned. It is suggested that several techniques should be used to assess risk in detail. Employing only one technique, for example prostate specific antigen, may result in men undergoing unnecessary surgery or inappropriate treatment. Nurses have a professional duty to ensure that they are aware of the advantages and disadvantages with respect to screening men for cancer of the prostate. Patients' must be in possession of the facts before they make important decisions about their health. In order to reduce harm the nurse can become the patient's advocate and act in such a way as to safeguard and promote the patient's interests.     

Stability of intact chorionic gonadotropin (hCG) in serum, liquid whole blood, and dried whole-blood filter-paper spots: impact on screening for Down syndrome by measurement of free beta-hCG subunit

The use of multiple maternal serum biochemical markers in screening for Down syndrome is gaining worldwide acceptance. We sought to study the impact of the potential instability of intact human chorionic gonadotropin (hCG) on free beta-hCG subunit, a marker that has recently been used successfully in such screening. We found that, in practice, any changes in free beta-hCG due to the instability of intact hCG do not inhibit the effectiveness of free beta-hCG as a marker for Down syndrome. This was proven by controlled laboratory experiments at various stress temperatures, freeze-thaw studies, and analysis of a large set of screening data with particular reference to time in transit for individual samples. Data from controlled dissociation studies demonstrate that any apparent increase in free beta-hCG due to the instability of intact hCG cannot be attributed simply to the dissociation of intact hCG. Finally, for large-scale mass population screening in areas of the world where transport delays, safety concerns, and high temperatures preclude the shipment of liquid whole blood, dried whole-blood spots in filter paper provide a suitable delivery system with many advantages.     

Use of screening mammography and its demographic and risk determinants in women 25 to 65 years of age

BACKGROUND: To know the utilization of the screening mammography among women from 25 to 65 years old in an urban health zone, where there is not an specific screening program for breast cancer. To detect the demographic and risk determinants that are involved in the mammography screening use. SUBJECTS AND METHODS: A sample of 1,240 women were interviewed consecutively as they visited their physician. Risk factors, sociodemographic variables and use of health services were analyzed. The associated variables with the use of mammography screening were determined by univariant analysis. A multiple logistic regression model was designed to identify the variables independently associated with the use of mammography screening. RESULTS: The percentage of interviewed women who have completed at least one mammography screening in the last three years has been 10.2 +/- 3% (confidence level: 95%), 68.3% of them were under 50 years old. The variables independently associated with the use of mammography screening were: age (OR = 1.08); routine visit to the gynecologist (OR = 8.13); educational level (primary: OR = 2.44, secondary: OR = 3.66, university: OR = 7.43, no schooling: reference level); and knowledge about the benefits of mammography screening (OR = 6.15). Family history of breast cancer and the other risk factors were found not to be associated with the use of mammography screening. CONCLUSIONS: The use of mammography screening among women from 25 to 65 years is inadequate according to the age and other risk factors. Mammography screening among women with a family history of breast cancer and those over 50 years old is underused, so it would be recommended and their use increased for these women. But women under 40 years old without family history of breast cancer have to be dissuaded from undertaking such a screening.     

The benefit of appropriate empirical antibiotic treatment in patients with bloodstream infection

Sudden cardiac deaths of young athletes, which are usually associated with physical exertion, continue to achieve high public visibility and generate considerable concern. Despite broad community participation in sports, such catastrophes are uncommon, occurring in about 1/200000 high school athletes per academic year. Various unsuspected congenital cardiovascular diseases are usually responsible; the most common lesions are hypertrophic cardiomyopathy and several congenital coronary artery anomalies. Selected reports suggest that arrhythmogenic right ventricular dysplasia may be a more common cause of these deaths than previously suspected. In some trained athletes with borderline increases in thickness of the left ventricular wall, mild morphologic expression of hypertrophic cardiomyopathy can often be distinguished from the physiologic consequences of athlete's heart by noninvasive clinical assessment and testing. In addition, the recognized cardiovascular risks of the athletic field are now extended to include cardiac arrest resulting from relatively modest, nonpenetrating chest blows produced by projectiles (such as baseballs) or bodily contact in the absence of underlying cardiac disease and without structural injury to the chest wall or heart. These uncommon but usually fatal events seem to result when chest impact occurs precisely during the vulnerable phase of repolarization, and they may be reduced by use of softer baseballs. Preparticipation screening for cardiovascular disease, consisting of standard history and physical examination, is customary practice for most high school and college athletes in the United States. Evidence suggests, however, that the present screening process for cardiovascular disease in high school athletes may be largely inadequate, given the content of the approved screening questionnaires (which serve as guidelines for the process) and the use of examiners with little cardiovascular training. This emphasizes the need for national standardization of preparticipation screening. The recommendations of the 26th Bethesda Conference for disqualification from competitive athletics are now a standard for management decisions when cardiovascular abnormalities are identified in trained athletes.     

CD1d-mediated recognition of an alpha-galactosylceramide by natural killer T cells is highly conserved through mammalian evolution

BACKGROUND: Although increasing rates of breast carcinoma incidence have been observed in Asian countries, appropriate strategies for detecting early stage breast carcinoma in such communities have been difficult to formulate, particularly because no large population screening trial specifically involving Asian women has been reported. The objective of this study was to evaluate the effectiveness and quality of mammography as a screening technique for Singaporean women, who are predominantly Chinese. METHODS: In this prospective study, 166,600 women in Singapore ages 50-64 years were randomized to either 2-view mammography without physical examination (67,656) or observation (97,294, controls) over 2 years. RESULTS: Of these women, 28,231 (41.7%) responded and were screened; they were more likely to be married, have more formal education, be working, be Chinese, and be in a higher socioeconomic group (P < 0.001 for all variables). To assess for response bias that could affect outcome, results were also evaluated for nonrespondents (n = 39,425). The incidence rate of cancers among nonrespondents (1 per 1000 woman-years) was less than the 1.3 in women not invited to have screening (P = 0.03, relative risk [RR], 1.3; 95% confidence interval [CI], 1.0-1.7). However, cancers arising from nonrespondents did not differ significantly in stage distribution when compared with cancers within the control group. For every 1000 women screened, 4.8 cancers were detected. The prevalence ratio (the number of cancers detected per 1000 women at first screening divided by the corresponding incidence rate in controls per year) was 3.6 for screened women and 2.4 for women invited to have screening. The majority of cancers detected through screening were early stage, with 64% as either ductal carcinoma in situ (26%) or Stage I disease (38%) and was significantly more than the corresponding 26% in women not invited to have screening (P < 0.001). When only invasive cancers were considered, screened women still had more early cancers, with 65% having no lymph node involvement, compared with 47% in the group not invited to have screening (P = 0.001; RR, 1.4; 95% CI, 1.2-1.7). Women who were screened had half the risk of having Stage II or later cancers (P < 0.0001; RR, 0.5; 95% CI, 0.4-0.7) when compared with women not invited to have screening. This higher detection rate of early cancers through screening was accomplished with acceptable recall rates of 8% for further mammographic films or physical examination and a biopsy rate of 1.0% (10 per 1000 women screened). The interval cancer rate was 2.1 per 10,000 women screened in the first year of follow-up. CONCLUSIONS: These positive results of intermediate measures suggest that, in Asian communities, screening mammography could be an important modality for detecting early stage breast carcinoma. However, the low compliance rates suggest that health education efforts must focus on issues related to acceptability if such programs are to succeed.     

Screening for colorectal cancer by immunochemical fecal occult blood testing

Screening for colorectal cancer using the conventional Hemoccult test has been shown to reduce mortality associated with cancer by 33% through a randomized controlled trial. However, the magnitude of effectiveness is small in terms of cost-effectiveness. The recently developed immunochemical fecal occult blood test (IFOBT) provides a potential replacement for the Hemoccult test as a screening test, due to its superior performance characteristics such as higher sensitivity shown in preliminary studies and the fact that it does not require any dietary restriction. The IFOBT method is reviewed, especially in relation to its specificity. In known colorectal cancer subjects, IFOBTs have shown both higher sensitivity and specificity than the Hemoccult test. Similarly, IFOBT has demonstrated a higher sensitivity than Hemoccult for colorectal cancer in an asymptomatic population. A nationwide screening program in Japan has demonstrated the feasibility of this approach for large population screening. However, the positivity rate varied according to the conditions at each screening facility. Therefore, technical factors that influence the positivity rate of IFOBTs in the screening program are discussed. Case-control studies have strongly suggested that screening using IFOBT would reduce mortality from colorectal cancer by 60% or more. Several observational studies have provided support for this estimate. The feasibility and effectiveness of population-based screening by IFOBT are discussed.     

Heparin-induced thrombocytopenia

Seen from a societal perspective, the health gains that might result from prostate screening are too uncertain to justify the substantial associated costs and adverse health effects. Clinicians who rely on observational screening studies to justify current screening practices should be aware of the potential biases that render conclusions suspect. Medical history documents numerous cases of medical interventions that appeared reasonable at the time, but ultimately proved worthless and even harmful. Before embarking on an ambitious screening program for prostate cancer, clinicians should demand that five basic criteria are satisfied: (1) that prostate cancer is a significant health burden, (2) that screening can identify localized disease, (3) that tests used in screening programs have acceptable performance among the population being tested, (4) that the potential for cure is greater among patients with screen-detected disease, and (5) that screen-detected patients have improved health outcomes compared with those who are not screened. Randomized trials provide the best methodology for determining the efficacy of screening and treatment. Clinicians are often too quick to credit medical intervention for successful outcomes and blame tumor biology for disease progression. Furthermore, when faced with a decision of administering or withholding therapy, physicians generally wish to err on the side of having done everything possible. Data modeling can provide critical insights concerning these issues using currently available information. Three recently published models suggest that the overall benefit to a population of men screened for prostate cancer can be measured in days of additional time of life gained, not months or years. Furthermore, models suggest that a substantial number of men need to undergo treatment in order to avert a single cancer death. The costs of implementing a screening program are enormous and deflect resources away from alternative uses, such as increased basic science funding to identify a cure for this disease. Therefore, based on the evidence presented, I believe that without more substantial data supporting the efficacy of screening programs, screening for prostate cancer is neither appropriate nor cost-effective.