Cancer risk, cancer screening, cancer controversy

The whole issue of the appropriateness of cancer screening is starting to become a major public health issue, closely and inevitably associated with cancer risk.

The “New” Prostate Cancer Infolink believes we can expect strong feelings to be expressed on both sides of this issue over the next few years, and we want to go on record now as stating that the currently available data for and against the appropriateness of screening for almost every form of cancer is generally very poor.

Assumptions have long been made that if we screen people for cancer, we can detect it earlier and reduce risk of cancer-specific deaths — and there are a very few cancers for which that is certainly the case. The validity of these assumptions, however, depends on the quality of the screening tests used to “detect” each form of cancer. Unfortunately, one of the very real problems with many of the tests we are using today is the detection of biologically evident but clinically insignificant cancers that place patients at minimal risk of serious forms of cancer but at high risk for over-treatment and the potential consequences of such over-treatment. And this doesn’t just apply to prostate cancer!

In the Wall Street Journal Health Blog last Friday, writing about the rising costs of health care, Peter Landers referred to an article in the German magazine Der Spiegel. In that article, Der Spiegel stated that there is “a growing movement for cancer testing in Germany,” but went on to claim that “screening for breast, prostate and colon cancer does hardly anyone good except for the doctors who can rake in fees from health insurers.” Apparently German doctors “get the equivalent of $270 or so from German health insurers every time they perform” a colonoscopy. In addition, “Germany is soon to become the first country to introduce universal skin-cancer screening.” Der Spiegel also “quotes a top official as saying the move followed ‘massive pressure’ from the public and dermatologists ‘in spite of weak evidence.’ ”

The “New” Prostate Cancer InfoLink is well aware of the political pressures that come from many quarters to implement specific types of screening program for a multitude of diseases. Cancer survivors naturally tend to think that everyone should be “protected” from what happened to them. So do those who suffer from everything from multiple sclerosis to Alzheimer’s disease and Guillaume-Barre syndrome. It’s human nature. But at the other end of the scale we need some realism. Most of us aren’t exactly good at the idea of preventive health care to begin with. Should we really expect society to pick up the tab from screening us against everything that could do us harm? Should our physicians really be benefitting financially from hunting down clinical indicators of potentially insignificant forms of clinical condition — especially in the elderly? Where do we draw the line?

In the United Kingdom, home of the world’s largest system of socialized medicine, the BBC News reports today that, “The reluctance of men to adopt a healthy lifestyle and visit the doctor may be fuelling a gender gap in cancer cases and deaths.” Data published by the National Cancer Intelligence Network and Cancer Research UK has indicated that “among cancers which affect both sexes, men are 60 percent more likely to develop the disease and 70 percent more likely to die from it,” but “there is no known biological reason for this,” the report stated.

According to a report in a newspaper called Daily Mail, the investigators “expected both sexes to be at equal risk of cancer,” but noted that “men are more reluctant to complain … about symptoms and often leave it too late for the disease to be treated.” Is it true that women really take better care of themselves, or is this just another form of sexual stereotyping?

Apparently, in 2006, 293,601 people in the UK got a diagnosisof cancer — 147,223 men and 146,378 women. In 2007, however, there were 155,464 deaths from cancer — 80,907 in men and 74,557 in women. The overall cancer mortality rates for 2007 were 211.3 per 100,000 in males and 153.1 per 100,000 in females “owing to a combination of different life expectancy and the increased likelihood of men having more fatal cancers than women.” Furthermore, “men were 16 percent more likely to develop any type of cancer in the first place, but more than 60 percent more likely to develop cancers that can affect both sexes, excluding those that affect just one sex.”

We are never going to be able to resolve any of these issues until be get a lot better at at least some — and preferably all — of the following:

  • The early differential diagnosis of cancers by clinical risk — in other words, being able to have much better understanding at the time of diagnosis of who really needs aggressive treatment because their cancer may either shorten their life or severely affect its quality
  • Explaining to individual patients why aggressive treatment may not be  in their best interests if they have every indication of low risk, indolent forms of cancer
  • Alignment of physicians’ financial reimbursement with truly appropriate medical practice — so that a urologist (for example) is as reasonably compensated for convincing a 70-year-old patient that expectant management is probably an excellent form of care for his prostate cancer, given his particular circumstances, as the urologist would be for carrying out a radical prostatectomy
  • Teaching society that the vast majority of cancer diagnoses have long since ceased to be a death sentence (although there are still plenty of exceptions to that statement)

The psychology of “cancer survivorship” may also not be in our best interests as a society. We use the term today even for those who are treated for the very earliest forms of cancer — surgical removal of a tiny melanomatous mole in a person at high ethnic risk for melanoma is a classic example. The historic unwillingness to admit to a diagnosis and the social avoidance of cancer as a topic for discussion has been replaced by something approaching pride in being a cancer “survivor” — but this makes no more sense to this author than our unwillingness to accept that the way we have been polluting the environment has probably caused a very large proportion of the cancers we suffer from!

We are bad at “balance.” We want to see things in simple colors. But neither life nor cancer come, much of the time, in these simple colors. To make progress, we need to become a lot better at using all the Crayola colors in the box to construct better pictures of reality.

4 Responses

  1. Some fair points expressed there relating to the general field of screening.

    I believe the recent AUA guidelines (Best Practice Statement) are the most accurate so far in clarifying the initial testing procedure for possible prostate cancer using the tools we have available today, i.e., PSA and DRE tests. I would be very interested to see if (and that’s a big IF) they were taken on board on a global scale what results would appear on both the saving of lives along with the financials over a 10-year period — as in “if I could see the figures now.”

    On a global scale we need some common tighter baselines to work from and I think the AUA have got it just about right. Don’t have a national screening program if the country can’t afford it but make men more aware of prostate cancer. Encourage men to get tested at 40 to enable the early detection of potentially aggressive “Tigers” that can then be treated at an earlier stage or just to getg a baseline for future reference. They might not need another PSA test for 5 or 10 years but then a bit of history is available to aid any future testing/procedures.

    Just my views and I don’t expect everyone to agree with them.

  2. Mike:

    Sensible commentary on the screening issue. However, I disagree on one aspect — whether your comments can be applied across the board to the whole population of a country.

    Certain demographic cohorts may be more at risk from late diagnosis and death and therefore may justify a government-funded marketing campaign urging them to get tested. This is the approach taken by the NZ government for breast and cervical cancer, but the TV campaigns urging screening are aimed specifically at Maori and Pacifica people because their cancer stats are much worse. The same should apply for prostate cancer. Maori men die at twice the rate of Pakeha (white) males, partly because their macho approach to having medical checks tends to be more pronounced than that of other men, and they are poorer and less educated. They scarcely fit the American Urological Association’s “well-informed” man profile.

    Does this sound familiar? The black American population seems to have a similar profile, although the reasons may be different. So — yes — hold back on the big population-based screening campaigns for the whole male populace, perhaps, but some ethnic groups (especially indigenous ones who suffered adverse affects from colonialization, like Maori) may warrant a more proactive approach, certainly in terms of education campaigns.

  3. Jim:

    I don’t think we are actually disagreeing about anything. Your point is about the need for education of specific subsets of the population of specific nations. I agree that that is essential. My point was about whether we really have appropriate data to justify population-based screening (as opposed to well informed testing of individuals based on risk) in any or all populations or subsets thereof.

    Are Maori, African-American, and Afro-Caribbean males at higher risk for prostate cancer than the average Caucasian today? Yes. Do we really have a clue why? No, not really — although diet may be one factor.

    The bottom line for me is that our policies about population-based screening to date have been based less on good science than on fear and commercial interests. We need to do a better job of the whole issue.

  4. Mike,

    I applaud your continuing efforts to educate men on prostate cancer. The points you make about screening, diagnosis, reimbursement, and teaching are all dead on.

    You are certainly facing an uphill battle. It seems that for doctors, advocacy groups and major organizations like the ACS, as far as the first three points are concerned, the continuing message is that “more is better.”

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