Stop giving men a bum steer on prostate cancer
“Raising awareness” is a catchcry for cancer events. Prostate cancer awareness is complicated like no other cancer by the mixed messages on early detection.
Urologists and pathologists urge men over 40 to get tested regularly; others in the clinical community involved in cancer screening advise men to make an informed choice about being tested, after discussing their family history and other personal concerns with their GPs.
Why the debate? Because there’s no screening test that adequately distinguishes between an early-stage prostate cancer that may lead to a patient’s death if untreated and a cancer that will do no harm in the patient’s lifetime.
This would be OK if the results of unnecessary treatment caused no harm, but invasive prostate surgery leads to high levels of impotence, incontinence and permanent discomfort. These are serious quality-of-life matters.
For context, the most comprehensive study of prostate cancer screening with the PSA test showed that for every man whose life was saved by the test, 48 underwent invasive treatment for no benefit.
On a population basis, this puts the risk of harm above the potential for benefit. That’s why the Australian Health Minister’s Advisory Council, which represents all nine Australian health departments, in partnership with Cancer Council published a statement recommending informed individual choice rather than population-based screening.
Despite calls for men aged 40 and over to be regularly tested, the fact is no government in the world has introduced a population-based prostate cancer screening program using the unreliable PSA test. And I don’t think any ever will.
Even the inventor of the test, Dr Richard Ablin, branded PSA “a public health disaster” and “hardly more effective than a coin toss”. It’s difficult to imagine the creators of the Pap test for cervical cancer, breast mammography or faecal occult blood testing for bowel cancer saying the same; these tests save lives with minimal side effects compared with the harms of over-treating prostate cancers.
Urging men to be tested from 40 also sends a misleading and potentially alarmist message. On average about eight Australian men in their 40s die from prostate cancer each year. That’s a terrible tragedy for those men and their families – like all death.
But should we risk consigning hundreds of others to a life compromised by impotence, incontinence and discomfort because they underwent unnecessary surgery after acting on the results of an unreliable test? (Similar numbers of women in their late 20s and early 30s die from breast cancer each year, but we don’t recommend screening mammography for those age groups, as it is not reliable.)
Urologists make the point that they deal with the tragedy of men dying from late-stage prostate cancer, many of whom could have been treated effectively if diagnosed earlier. I understand and respect this perspective.
As a medical oncologist, I’ve treated hundreds of men with metastatic prostate cancer and feel just as strongly about reducing mortality. But not if the net population health harms of an unreliable screening test are shown in independent studies to outweigh the benefits.
My messages for prostate cancer awareness month are simple. If you have a family history or are concerned about prostate cancer, discuss it with your GP. Find out the pros and cons of the PSA test, so you can make an informed decision.
And we should all encourage investment in research to develop a more reliable test for this terrible disease that kills almost 3000 Australian men each year.
Professor Ian Olver is CEO of Cancer Council Australia
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