That Movember mo could be doing more harm than good
UPDATE: Dr Anthony Lowe, CEO of Prostate Cancer Foundation of Australia comments “Prostate cancer is a serious health issue in Australia – 3,300 men die from prostate cancer each year – more than the number of women who die from breast cancer, which is why it is so important for men to be aware of their prostate health. Contrary to Lauren Tracey’s statements in this article, PCFA does not advocate for population-based screening for prostate cancer. We support the position of Australian Health Ministers’ Advisory Council and Cancer Council Australia which encourages men to talk to their doctor so that they can make an informed decision about prostate cancer testing. We recommend that all men over age 50, or over age 40 with a family history of prostate cancer, talk to their doctor about testing as part of their annual health check. We advocate that men should make an informed decision based on the latest available evidence about the benefits and potential harms of testing and treatment.”
Movember. It’s that time of year where the lads of Australia cast that razor blade aside for 30 days and embrace that Tom Selleck look, which for those who are too young to have lived through, is an era they can only dream about for the other 11 months of the year.
For the ladies, it’s a time when we can get behind this charity event for men. With so many events directed at raising support and money for breast cancer that enjoy support from our colleagues, sporting teams and family members, it seems only right that this is the month that we all become champions for men’s health.
And on the surface, the Movember foundation supports worthy causes. Beyond Blue does great work with mental health issues, as does the Prostate Foundation of Australia. But I don’t entirely support Movember. To clarify, I specifically don’t support the Prostate Foundation of Australia’s stance on population-based screening of all men for this disease. And I am not alone.
The PCFA’s recommendation is for all men over 50 (and all men over 40 with a family history) to have annual screening via a prostate specific antigen (PSA) test and/or digital rectal exam (DRE). If the results of these tests show abnormalities, further testing is done by way of a biopsy for a definitive diagnosis, and if cancer is detected this can be followed by treatment, such as surgery or radiotherapy if the cancer is localised.
Sounds good, right? As with mammography for breast cancer in women, we are testing these men who are showing outward signs of being healthy with the intention of treating them early and preventing premature death from prostate cancer. But this is where the waters start to get muddied. Different from mammography, a PSA test will not find an abnormality like a lump, but instead gives a blood level reading which may be far from indicative of cancer.
The known drawbacks of the PSA test are that it can miss cancers (false-negatives), detect cancers that aren’t life threatening, or give an abnormal result even when cancer isn’t present (false positives). The physician that discovered PSA in the 1970s has described its subsequent popularity as a ‘public health disaster’ that is ‘hardly more effective than a coin toss’. It is not able to distinguish between those cancers which will go on to be fatal and those which will grow slowly and cause no harm.
Population-based screening for prostate cancer (i.e. screening all men in the population over a certain age) is not supported by such organisations as the Cancer Council, the Royal Australian College of General Practitioners or the Australian Government. This position is echoed by governments and health bodies across the world. A joint statement from the Cancer Council and the Australian Health Ministers’ Advisory Council shows that they are clearly at odds with the PCFAs position:
“Current evidence is that the harms of population screening with the PSA test outweigh the benefits. Consequently, either alone or combined with DRE (see ‘Testing’, above), the PSA test does not form the basis of a population-based screening program.”
An elevated PSA test on screening will require biopsy for diagnostic confirmation. In the meantime those with raised levels can experience increased anxiety, there may be complications from biopsies, death from subsequent surgery or sexual dysfunction and urinary incontinence associated with treatment. These can be devastating side-effects for the men who suffer them.
And at the end of the day, the reality remains that prostate cancer is a disease that more men will die with than from. Population-based screening will undoubtedly lead to over-diagnosis of prostate cancer and unnecessary interventions; the flipside being that not performing PSA tests on any men at all would prevent any chance of early detection and treatment in those who would see benefit, such as those identified as being at high risk.
Further research is needed to find a screening test and treatments that will offer men benefits that outweigh the risks. The PCFA are funding important work in this field, commendable work that is achieved through generous donations.
So what is the answer? Deciding on whether or not to have a PSA test is a personal decision that men should make in consultation with their GP, taking their individual risks and the potential harms and benefits into careful consideration. What shouldn’t be happening is men being told they need to ‘be a man’ and ‘not die of embarrassment’, or as Magda Szubanksi suggested in a 60 Minutes interview, that men ‘don’t be a pussy’ and have a check.
This is a serious issue that needs serious consideration, not to be trivialised by goading men into having screening that may not be beneficial. So this Movember I will be bailing up my mates at the wrap up party with my usual spiel on prostate cancer screening. At 28 years old it is not an issue that many are thinking about at the moment, but when the time comes, they need to have all the information available, not just a confusing message mixed up in a month of regrettable facial hair decisions.
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