Dr. Hahn is correct about the substantial controversy relating to the advisability and effectiveness of prostate cancer screening programs. Some patients may benefit from screening by early detection and treatment, whereas others should be left untreated.

My comment regarding efforts at earlier diagnosis of prostate cancer was not intended to imply that all cancers require treatment. Rather, potential curative therapy must be considered in high-risk patients in whom local or metastatic extension is likely.

Several end points are helpful in evaluating benefits from earlier intervention of localized prostate cancer. Regardless of overall survival benefit, preventing the complications of local recurrence, urinary tract obstruction, and other signs and symptoms of urinary dysfunction from an enlarging gland is important. Prevention of local tumor extension may or may not justify a radical prostatectomy. Future studies should identify histologic grade, differentiation, the extent of a primary tumor within the gland, and other variables to assist in a more discriminate therapeutic plan.

The letter from Drs. Bilgrami and Greenberg deserves special comment. The current data support the widespread use of flutamide as part of total androgen blockade in stage D₂ prostate cancer patients. The largest randomized controlled study of 603 patients by the National Cancer Institute (NCI) showed a 26% increased survival rate in the flutamide-plus-leuprolide group compared with the leuprolide-placebo group [1], especially in patients with minimal disease and small tumor burden. Quality of life, including decreased pain and improved disease-free progression, was also better. Another study supported the addition of flutamide to either luteinizing hormone-releasing hormone analog therapy or orchiectomy [2]. Studies that have not shown a benefit of total androgen blockade have had methodologic deficiencies such as the inclusion of other than stage D₂ patients, small patient numbers, and no double-blinding or placebo control [3, 4].

The cost of flutamide compared with that of other antineoplastic agents is modest. In the NCI Intergroup Study [1], the marginal cost of adding flutamide was estimated to be $7500 over a 3-year period. The increase in years of life saved was 7.3 months or 0.61 years. The cost per year of life saved by adding flutamide is $12 300 ($7500 divided by 0.61). This compares favorably with other health investments, such as the implantable defibrillator, estrogen replacement therapy for postmenopausal symptoms, and continuous ambulatory peritoneal dialysis. Cost-effectiveness is greater if the analysis is restricted to patients treated with flutamide who had minimal disease and an excellent performance status.