Another Blow to Men’s Health
The decision of the health select committee that there will be no National Prostate cancer screening can only be described as short-sighted. Once again, the opportunity to create a world class preventative health program is slipping through our fingers. Conventional thinking, like that exhibited by Associate Professor Brian Cox of the Dunedin School of Medicine, dictates that the two cornerstones of prostate cancer screening – the digital rectal examination and the Prostate Specific Antigen (PSA) blood test – are both very unreliable. While this is superficially true, both tests producing many false positives and false negatives, the conclusion that prostate screening is not worthwhile does not necessarily follow from this.
The usual objection to large-scale screening is that such screening leads to “over-diagnosis” of prostate cancer and hence to much unnecessary treatment of “normal” prostates. This is an oversimplification. The real reason that there is much over-treatment of otherwise benign prostate disease is that there is a large overlap between benign prostate enlargement, pre-cancerous conditions and cancer itself. Even biopsy of the prostate (taking a small sample using a special needle) does not always provide a definitive answer. Most prostate cancer cells are very slow-growing and hard to differentiate from normal benign enlargement.
The equivocal nature of even a biopsy is the reason why studies of prostate screening programs yield equivocal results. The new Swedish prostate trial, mentioned in the quoted articles, is the latest one to cast doubt on the utility of a screening program. However, even a quick read through the abstract tells you that the screening program consisted of only a rectal examination for the first two examinations, with the addition of a single PSA for the third. No screening program designed today would rely on such a design.
The latest evidence on PSA screening for prostate cancer indicates that it is the velocity of PSA (how fast it is rising) that is important, rather than a single value. Any modern screening program would therefore incorporate an annual PSA with a rectal exam every, say, three years. A hard lump felt in the prostate or a rapidly rising PSA would be grounds for referral. Equivocal biopsies would then be regularly monitored by serial PSAs.
A screening program such as this has a good chance of making serious inroads into prostate cancer deaths. New Zealand could be the pilot for such a screening program. While it is possible that this may turn out to be a waste of money, there is sufficient evidence to make it a very worthwhile experiment. Currently, little is being done to try and reduce prostate cancer deaths in New Zealand and this has more evidence going for it than many other interventions, including most of our anti-smoking programs.
The thing is, compared to mammography for breast cancer screening, this kind of program is dirt cheap. It is worth doing even if it does turn out to be less successful than hoped. Over-treatment is not generated by the screening, but by the equivocal nature of the biopsy. It therefore makes little sense to suggest that only urologists should do PSAs, as restricting PSA tests to urologist will diminish referrals for potential prostate cancer. This will merely ensure that prostate cancer that would otherwise be caught early is not referred soon enough to save a life. The over-treatment issue should not be solved by a bizarre “see no evil” approach to prostate screening, but by improved methods of eventual diagnosis.
For the sake of a relatively small amount of health dollars, men’s health is once again being ignored. Seeing as I have yet to meet a urologist who is not in favour of regular PSA screening, one wonders who is advising the select committee and what their priorities are. I can’t help feeling that one would see a little more enthusiasm for a screening program if prostate cancer was not an exclusively male problem.
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Apr 6 11 6:41 am
Excellent post Macdoc. Unfortunately, prostate cancer isn’t “sexy” like breast cancer or cervical cancer, given that it affects primarily elderly men; that makes it far harder for campaigners for screening programmes to get any traction; they can’t trot the Kylie Minogues of this world out in front of the cameras.
I lost my father to prostate cancer, so I guess I have a vested interest. I agree with you that any life saved is worth it, especially to the person concerned and those close to them. Let’s hope that a future government can be persuaded to take prostate cancer seriously.
Inventory2´s last [type] ..Half a million
Apr 6 11 4:38 pm
Of course prostate cancer needs to be taken seriously. But there is little value in a screening programme when the medical profession is so divided on what to do when cancer is actually detected, i.e active treatment versus “watchful waiting” of a cancer which is, for the most part, indolent. Some researchers claim that the majority of men over 75 will have prostate cancer to some degree, but fortunately most will not suffer any ill effects (i.e will die of other causes before it causes them any bother). Much more understanding of the disease itself is needed before wholesale screening is done.
Apr 6 11 6:58 pm
While your observations are pertinent, Prostate cancer is still a killer disease in younger men (below 65 yrs). There are plenty of instances where there is no doubt that the tumour needs to be removed. Where there is doubt, “watchful waiting” is quite acceptable. We do not entirely understand breast cancer, but we treat it successfully (and unsuccessfully) every day. Should we abandon mammography while we come to a better understanding of the disease process of breast cancer?
Apr 7 11 10:56 pm
“Some researchers claim that the majority of men over 75 will have prostate cancer to some degree”
Interesting. Never heard that one before. Do you maybe have a link to the source, Rod? Appreciated.
Andy´s last [type] ..Cruises out of Galveston
Apr 8 11 9:10 am
There are quite a few references out there giving varying percentages of incidental prostate cancer found at autopsy in men who have died of other causes. This is but one:
http://www.fpnotebook.com/Urology/Hemeonc/PrstCncr.htm
Interesting to note that if you survive to age 90, the chances of having incidental prostate cancer are 100%!
Try googling “let sleeping dogs lie?” by Simon Chapman et al,; there is a 100+ page pdf available which is very enlightening. A study listed there gives a 46% likelihood of incidental PC in the 70-81 age group.
Apr 6 11 8:58 am
As one who has recently been through the raised PSA and subsequent biopsy routine, I think you have overlooked a very important aspect – the anxiety caused by the possibility of having prostate cancer, and the fact that a positive diagnosis often does not increase life expectancy. Treatments for prostate cancer (prostatectomy or radiation) can in fact in themselves cause harm relating to a significant reduction in the quality of life. Added to this is the continuing use of the PSA test, which only indicates that all is not well with the prostate, and is not a definitive indicator of prostate cancer. More definitive tests need to be developed (PCA3 perhaps?) to make screening a worthwhile proposition.
For the record, my biopsy did not detect cancer. So it is thought that my raised PSA is due to some form of prostatitis. But nobody can give me a definitive answer, just prescribe antibiotics (which do nothing but make me feel unwell), and so the anxiety remains.
Of course you have never met a urologist who is not in favour of regular screening. It’s their bread and butter. Am I being too cynical?
Apr 6 11 10:14 am
“Of course you have never met a urologist who is not in favour of regular screening. It’s their bread and butter. Am I being too cynical?”
I think you are. There are people alive today who would not be if they had not a PSA test.
The thing that should be looked for with a PSA tests is a trend not one reading.
Apr 6 11 4:24 pm
“There are people alive today who would not be if they had not a PSA test”.
Agreed. But there are also people who are incontinent or who have other health issues as a result of treatment for prostate cancer, which possibly may not have had any effect on longevity or quality of life. I feel that at this point money needs to be spent on researching this poorly understood disease, rather than on screening programmes of unknown effectiveness.
Apr 6 11 7:02 pm
I do not accept the meme that screening is the cause of such poor outcomes. Surely what needs to happen is better investigation and treatment. The best way of doing this is to discover tumours as early as possible so that less aggressive and debilitating treatment can be carried out.
Apr 6 11 3:20 pm
Men must get smart. Go to your GP and get an annual PSA, and get a rectal exam if you are older. It will only cost you the GP’s fee which is not much considering the effect it could have on your life.
Apr 6 11 11:54 pm
Totally agree with these two complementary measures (rectal exam and PSA test). My GP adds a third measure which is to be aware of any changes occurring. My wife calls the latter “the gap”, although this is just as likely to be the result of poor aim in the dark.
Apr 7 11 8:33 am
The nub of this issue is whether we need a widespread screening programme. It is obvious from comments on here that screening is already happening on an individual basis. Surely the way to go is education, then the individual can take up the issue with their GP as they see fit. Isn’t taking personal responsibility for one’s own health what it’s all about?
Apr 7 11 8:54 am
Isn’t taking personal responsibility for one’s own health what it’s all about?
It is clear that you have never worked in the health industry…
Apr 7 11 10:54 am
You’re right….but what I have seen from the user side is that it’s all about money. Example: following my prostate biopsy, the urologist charged me $150 for a five minute consultation, so he could tell me what his receptionist had already told me on the phone. I got more detailed information from the receptionist…
Apr 7 11 9:20 pm
Now you’ve moved the topic to the cost of specialists. I’m afraid you are on your own there. Too scary…
Apr 7 11 9:53 pm
I thought I might be….the cone of silence descends. But it’s not the cost that’s scary, it’s the lack of value which frequently follows. People seem to accept a lower level of service from medical people than they would ever tolerate from their mechanic or plumber. GPs can be as bad; just cheaper…
Apr 27 11 10:46 pm
I was told that by the time you know you have it, you are to old to treat, That may have been ok when we all died at 60 but we are now living to 80