Of black and white and shades of grey

For many years now, the prostate cancer “screening” issue has been framed by two opposing and “extreme” points of view.

On the one hand, much of the urology community and many in the survivor community have argued that regular testing of all men over some specific age is essential if we are to find and treat prostate cancer effectively. On the other hand, many in the epidemiology and public health community have argued that there are minimal data to support such a rationale, that the cost is inordinate, and that the numbers of men who are harmed by such a strategy is far greater than the numbers of men who benefit.

What is all too often ignored in this discussion is the right of the individual man to make up his mind what he wants to do once he has received an unbiased and straightforward assessment of the available data. For The “New” Prostate Cancer InfoLink this is at the very heart of the issue. Nearly every day we are shown, over and over again, that men are not given either simple and accurate facts about prostate cancer risk or the personal risk factors that might make them feel the need to undergo testing. And without that information, the academic arguments for and against “screening” are (frankly) irrelevant — they simply prejudice behavior.

We have pointed out (on a regular basis) that the data in support of annual, mass, population-based mammography as a screening tool to identify risk for breast cancer are no better than those for the use of the PSA test as a means to assess risk for prostate cancer. Women are as much at risk for the harms resulting from breast cancer screening as men are for the harms of prostate cancer screening. But we would all defend to the hilt the idea that a woman had the right to make her own decisions about whether to have regular mammograms and to be appropriately informed about the value of this test (or at least, I sincerely hope we would).

In their statement that followed the publication of data from the PLCO and ERSCP screening trials earlier this year, America’s Prostate Cancer Organizations stated, very simply, that:

  • “Every man, regardless of his age, has the right to know whether he is at risk from prostate cancer,” and that
  • “We shall continue to encourage every man to discuss his individual risk for prostate cancer with his doctors, and to request the appropriate use of PSA and DRE tests until better options are available.”

It really doesn’t matter whether you personally espouse an extreme view in favor of or against mass, population-based screening or you are prepared to admit that we just don’t have the tests we need to help discriminate between the men who most need early diagnosis and the men who are at greatest risk for unnecessary treatment of indolent disease. These two simple ideas are fundamental to helping individual men make good decisions about what they, personally, should do on behalf of themselves and their families.

On July 5, 2009, the day after the 233rd anniversary of the signing of the Declaration of Independence, it seemed like a good idea to remind anyone who happened to read this that individual freedom to make decisions about what was good for a man and his dependents was at the very heart of that Declaration in 1776.

Perhaps we should be more more cognizant of that individual freedom as we discuss the controversial issue of prostate cancer “screening.” The ongoing Civil War on the topic does little good for anyone except the media.

12 Responses

  1. Thank you.

  2. Well said, Sitemaster.

  3. I keep hoping those who are so adamant and outspokenly opposed to early detection of prostate cancer in adult American males will come up with constructive alternatives to inexpensive PSA and DRE testing.

    I could not care less whether Dr. Otis Brawley agrees or disagrees but when he speaks as the chief medical officer of the American Cancer Society he assumes the responsibility of an authority whose statements may encourage high-risk men to do nothing.

    Phil Olsen

  4. Yep, well said and a balanced view which is sadly missing from the media.

  5. The US Preventive Services Task Force gives screening for breast cancer by mammography a B recommendation. (“The USPSTF found at least fair evidence that [the service] improves important health outcomes and concludes that benefits outweigh harms.”) While not nearly as effective as the general public seems to believe, the evidence for the efficacy of breast cancer screening by mammography is significantly better than that for prostate cancer screening, which a receives an I recommendation (insufficient evidence) for men under 75 and a D recommend (no benefit or harms outweigh benefits) for men over 75).

  6. Phil:

    You got that absolutely right!


  7. To be a fraction more accurate, USPSTF gave screening for breast cancer by mammography a B recommendation in 2002 — but only for women between the ages of 50 and 69 years of age. This guidance has not been updated since that date, but we would expect an update shortly.

    That update may be as controversial as the prostate cancer document, since there are now plenty of authorities that dispute that viewpoint. You might want to look at the commentary on this topic on the Breast Cancer Action web site, as well as BCA’s policy on breast cancer screening and “early detection”. These statements are from a breast cancer group that “carries the voices of people affected by breast cancer to inspire and compel the changes necessary to end the breast cancer epidemic.” We can reasonably assume that they would be recommending any test that they thought worked.

  8. “What is all too often ignored in this discussion is the right of the individual man to make up his mind what he wants to do once he has received an unbiased and straightforward assessment of the available data.”

    In what Medicoutopia would that happen? I can’t see it unless a law were passed.

  9. Dear Leah: This is not a medical problem. It is a social and educational problem. There is plenty of information available, which men ignore because no one has ever taught them it is important.

  10. I have no idea what the qualifications of the Breast Cancer Action group are. My point is that, as of 2002, the evidence of efficacy versus harms, as evaluated by a highly qualified, impartial panel of experts, was sufficient to recommend breast cancer screening by mammography for the appropriate age group. That is something that has never been true for prostate cancer screening. Perhaps the USPSTF will change the rating based on more recent studies, but we have no way of knowing that. Until then, the 2002 recommendation is the best anyone has to go on.

  11. This is a list of the studies on mammography from NBCC. It would be interesting to see a similar list of trials/studies for prostate cancer.

    It also might be better if the government guidelines on screening were what political decisions are based on.

    I am concerned that early detection for prostate cancer may be excluded for coverage if they use the USPSTF guidelines. As Mike said in the original post, men should have a choice. It seems wrong to take something away from men because there have been inadequate trials/studies to justify a higher grading.

  12. While it is an inalienable right of men to seek and know their prostate status and options, it is not a philosophical, social, or legal issue. It is an economic issue at the core.

    The US Preventive Services Task Force is the guardian of the federal coffers. Breast screen escaped, and the ladies will bloody well not brook any interference. Men, on the other hand, are such wimps that USPSTF is determined not to make that same mistake. “Evidence-based medicine” (more accurately, “economy-based medicine”) is the medical mantra, and its evaluation is subject to parameters that can only be described as biased.

    Case in point: Brawley et al. set great store by reduction of mortality rate as the acid test of efficacy of screen. They point to many studies, usually denigrating them as flawed. But somehow the SEER statistics are ignored when it comes to prostate cancer mortality:

    The 1975-2006 SEER age-sdjusted US mortality rates for prostate cancer represent a continuum from before aggressive screening, though the introduction of the PSA test, to a fully matured result of the aggressive screening era with the PSA test as the lead. The mortality rate peaked at 1993 at 39.400 per 100,000 population and has declined every year since, now 23.5600 per 100,000 in 2006. This is a 40.355% reduction in mortality from prostate cancer.

    If mortality is the proof Brawley et al. seek, how do they explain this dramatic decline of mortality rate from statistics gathered during the aggressive screening era?

    Is it cost-effective? That is another question, one that can get very subjective when seen through the eyes of the survivors, even more when seen by the families of those who didn’t survive, especially if they were dissuaded by learned medical people from being screened and educated and offered their own decisions.

    As the watchman of the federal dollars, USPSTF is doing its job by discouraging screening and aggressive treatment. “It’s the economy, stupid,” to borrow a phrase from an old presidential campaign.

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