In Prostate Cancer: Three Nations, Several Distinctions, posted below, we see trans-national comparisons of African-Americans, European-Americans, Asian Indians, and Senegalese. Now a five-nation analysis focuses on prostate cancer incidence and mortality in the Nordic countries of Iceland, Norway, Sweden, Finland, and Denmark.
The authors trace incidence and mortality due to prostate cancer in the period between 1980 and 2004. The findings are consistent with what has been seen elsewhere: incidence went up at the time that prostate-specific antigen (PSA) testing was introduced; the rise in Denmark’s incidence lagged behind the rest, which is consistent with its having introduced PSA last. In the period of 1996 to 2004 mortality began to drop in Finland and Norway; it stabilized in Iceland and Sweden; it continued to rise in Denmark, which introduced PSA last.
The authors conclude that the trends are consistent with a moderate effect of increased curative treatment of early diagnosed prostate cancer. In this, the report is consistent with an accumulating body of evidence from Tyrol, Seattle, and the US that shows an association of early detection with declining prostate cancer mortality rates.
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The relative level of ethnic/racial similarity within the Nordic nations is also important when considering the results of this study as compared to the study comparing patients in India, America, and Senegal. There are also significant similarities in things like diet, quality of health services, etc. The Nordic countries are among the nations with the very highest quality of health services across their entire populations.
These are like you say highly racially heterogeneous populations with high quality health services and data collection systems. There is a rich natural history of untreated prostate cancer in these nations that has been mostly ignored. Prostate cancer mortality in this region is very high. There has been great reluctance to detect and treat PCa there.
Ralph: There are several things that impact your comment above, as follows:
1. The fact that these nations have sophisticated health systems has also meant that they have excellent cancer registries. Therefore we know people were dying of prostate cancer. That wasn’t even true in America until relatively recently.
2. Acceptance of one’s mortality is a great deal more common in Europe than it is in the USA. This means that there tend to be a lot more people who (to use Paul C’s term) “would rather have 30 more good years than 40 less good ones.” It’s a cultural issue.
3. Life expectancy in all the Nordic nations (except possibly Finland, which used to have a very high level of alcoholism) has been relatively high for years. With high life expectancy comes an increased risk for death from all forms of cancer (now evident in the USA too).
I don’t think it is necessarily correct that the high level of prostate cancer mortality in the Nordic countries is a function of their health systems. I believe there are several other factors involved here. After all, their health systems are a contributing factor to the high life expectancy overall!
Mike,
The problem I have is in accepting that the 40 years are ALWAYS less good than the 30 good years. Progression of untreated cancer has symptoms and consequences. This is hardly ever recognized but needs to be part of the decision making process.
The very good health systems there with excellent cancer registries are a well of information to track the natural history of untreated PCa. I agree that a country’s culture and racial homogeneity has an influence in treatment decisions. Still, acceptance of the importance of early detection there has been slow…
Ralph:
I think that what has happened in Europe over the past 20 years compared to America is more about economics than it is about “early detection.” In the US there was (and to some extent still is) a very strong economic motive behind early detection of prostate cancer. This economic motive barely exists in Europe because of socialized medicine.
Please do not overinterpret what I am saying, but I can tell you exactly why Prostate Cancer Awareness Week got started in the US in 1990. It had everything to do with economics and marketing. The same applies to the use of LHRH agonists in the USA. At one point the cost of LHRH agonists was the single largest drug cost that Medicare reimbursed physicians for every year.
Hey Mike and Ralph:
Nice volley, I enjoyed reading your debate, thanks for the perspectives and education!!!
Karen