Dr. Wilt has misinterpreted the content of our two-part article as endorsing early detection and screening for prostate cancer. Our purpose in writing this Update was to inform the nononcologist of the current state of important developments in prostate cancer. We specifically did not address the issues of screening for the early detection of prostate cancer and referred to the forthcoming report by the Clinical Evaluation Task Force of the American College of Physicians.

Nonetheless, the comments by Dr. Wilt deserve rebuttal. Although we agree with the American Urological Association Panel that data on screening are inadequate to make a positive recommendation for widespread screening, the older man who presents to the internist's office for a complete physical examination presents a different issue. The recommendation of the American Urological Association and the American Cancer Society that an integral part of the physical examination in men 50 years of age or older should include a digital rectal examination and a test for serum prostate-specific antigen, as well as the tremendous upsurge in public interest in the early diagnosis and treatment of prostate cancer, have motivated many patients to request and undergo these tests. The internist who refuses to do a complete prostate evaluation while at the same time ordering a complete blood count, chemistry screening panel, and other tests not only misses an opportunity for early cancer diagnosis but may also find himself or herself in medicolegal peril should prostate cancer be discovered on a subsequent evaluation. These tests may be of vital importance for the individual patient, even though some may argue that the "cost-effective" benefit has not been well documented.

We agree with Dr. Wilt that the optimal treatment (if any) for prostate cancer remains in considerable doubt; however, we strongly disagree with the statement that including prostate-specific antigen testing and digital rectal examination as part of a routine physical examination would "result in prohibitive expense even if detection and intervention were eventually determined to be of clinical benefit." From our perspective as practicing physicians (not as policy or decision analysts attempting to interpret a confused medical literature), it is difficult, if not impossible, to place a monetary value on a human life. The charge to the physician in the day-to-day caring of patients is not to debate the value of wide-scale screening for prostate cancer but to do the evaluations that will best serve the needs of the individual patient who entrusts himself to the care of that physician.