A memo to the board of directors of the American Cancer Society

The American Cancer Society is not going to be very happy about a report issued today by the Cancer Prevention Coalition.

According to the report, and also a media release from the Cancer Prevention Coalition, the American Cancer Society is pretty much an “old boys’ network” that is primarily interested in the “accumulation of wealth” for a variety of interested parties.

The “New” Prostate Cancer InfoLink has had its own concerns with the American Cancer Society over the years, but this report from the Cancer Prevention Coalition appears to be a full frontal assault on the ACS. Among the specifics are the salary levels of of some of its senior executives and the amounts of money that the ACS spends on smoking prevention and salaries out of its annual $1 billion budget.

It is certainly the case the the ACS appears to think less about true cancer prevention and a great deal more about the diagnosis and treatment of selected cancers as a mechanism to raise money. The “New” Prostate Cancer InfoLink will leave others to make their own decisions.

Late last year, the Cancer Prevention Coalition issued a similar broadside against the appointment of Dr. Harold Varmus as the Director of the National Cancer Institute, stating that his points of view “should disqualify him from the NCI directorship.”

13 Responses

  1. Interesting report. It explains why Dr. Brawley shamelessly blames prostate cancer advocacy groups and urologists for being “in the pocket” of drug companies.

    The CPC report quotes a 2010 ACS report that states: “Regular screening examinations by a health care professional can result in the detection and removal of precancerous growths, as well as the diagnosis of cancers at an early stage, when they are most treatable. Cancers that can be prevented by removal of precancerous tissue include cancers of the cervix, colon, and rectum. Cancers that can be diagnosed early through screening include cancers of the breast, colon, rectum, cervix, prostate, oral cavity, and skin. For cancers of breast, colon, rectum, and cervix, early detection has been proven to reduce mortality. A heightened awareness of breast changes or skin changes may also result in detection of these tumors at earlier stages. Cancers that can be prevented or detected earlier by screening account for at least half of all new cancer cases.”

    PLEASE note that according to the ACS, prostate cancer is not among the cancers whose mortality rates can be lowered through screening.

    My conclusion: don’t donate to the ACS, don’t volunteer for them, don’t participate in any Relay for Life.

  2. Ummm … There is just one fly in this ointment … and that is that there are no data (so far) to prove that prostate cancer mortality can be lowered through screening in a population that has been highly exposed to the PSA test. The places where prostate cancer screening works are solely those populations where there has previously been no PSA significant and widespread PSA testing (e.g., the Goteborg study in Sweden).

  3. Hmm … Are you saying that the continuous reduction in mortality here is not happening? PSA use in the US has resulted in less deaths since 1992. The fly in the ointment are the actual results. Of course no one admits that the higher the use of testing with PSA, the less men that die of prostate cancer across the world. Breast deaths are down and prostate cancer deaths are also down, but prostate cancer deaths can’t be attributed to PSA testing yet … must wait for more evidence! In spite of ERSPC, Goteborg, Tyrol, and others.

  4. No Ralph, I am not saying that there isn’t a reduction in mortality. There most certainly is.

    What I am saying is that you cannot attribute that to “screening” (by which I mean annual, population-based testing with a PSA and a DRE) in the US population. Much of the drop in mortality today can be attributed to the expansion in use of the PSA test in the early 1990s, resulting in the stage shifting of a vast number of men who would otherwise have been diagnosed with node-positive or early metastatic disease in about 2000-2005. As you are well aware, there has been a massive reduction in the number of men diagnosed with N+ and M+ prostate cancer over the past 15 to 20 years. However, that was a major short-term effect, and is evidenced in the data on the numbers of patients diagnosed over the period from 1975 to 2007. The incidence rate clearly peaks in 1991 to 1993 at the beginning of the widespread use of the PSA test in the USA.

    In other words, annual screening “worked” in America for a brief period, between 1990 and 1994, just as it did in Goteborg a few years later.

    As I have said elsewhere (and often) , I don’t think annual screening is justified except for a subset of very high risk men. Most of us would be much better off having a PSA test once every 5 years or so. Five out of six men in America will never get prostate cancer at all (indolent or aggressive). Of course we will never be able to carry out any trial that could prove that hypothesis now.

  5. Sitemaster says: “…The places where prostate cancer screening works are solely those populations where there has previously been no PSA significant and widespread PSA testing (e.g., the Goteborg study in Sweden).”

    So, if PSA testing is widespread we don’t need screening, but if it is not widespread we do?

    So be it. As long as everybody gets tested, we can forgo screening. :-)

  6. There is always a distinction to be made in an argument that screening doesn’t work in a population vs. screening in an individual situation. I am one of those for whom it did work, catching an advanced prostate cancer at the age of 45 on my first exam. According to any criteria, I was not at high risk for age, race, family history or any other factor. And yet, I had it. Had I waited until the ACS-recommended 50, I would likely have been in a metastatic situation and have an entirely different outcome than I do now: cancer-free 2 years after a RALP. I understand there are economic considerations when looking at the question from a population level. But please tread lightly with the statement that “five out of six” will never get prostate cancer. One-of-six isn’t very good odds.

  7. Dear Reuven: Show men data from anywhere in the world in which annual PSA testing, or even PSA testing every 2 years, clearly demonstrates a survival benefit after the majority of men have received one PSA test. You can’t.

    All that I am saying is that annual, population-based “screening” of all men over 50 (or 40) does not have a survival benefit. By contrast, careful, risk-based testing is clearly associated with the identification of men who may benefit from treatment (which is a quite different concept). Getting a baseline PSA as one element of risk analysis is not the same as “screening.”

  8. Dear gr8rb885: That is exactly why I believe that getting a baseline PSA at something like the age you had your first PSA test is a good idea … but that is not the same as getting an annual PSA test (which is how “screening” is currently being defined).

  9. My support group invited the local ACS to speak to us. They sent a young woman to a prostate cancer survivor group. First mistake. The woman wanted to give the standard community report but the members were astounded at the prostate cancer stance of the Society. After spirited, respectful interaction she admitted she had to present an agency view which she could not personally support. Presenter and support group equally educated on the views of the other.

  10. Mike,
    You know that the word screening for prostate cancer is a myth invented to confuse the issue. There has never been a formalized prostate cancer mass screening for men here is the USA. What we had is more use of PSA in spite of the opposition to “mass screening”. The result has been a reduction in prostate cacner mortality. You say: “In other words, annual screening “worked” in America for a brief period, between 1990 and 1994, just as it did in Goteborg a few years later.”

    This is totally not accurate. First, this was not “screening”. There has never been screening here. This was individual use of PSA testing that discovered occult cancers before they presented with symptoms and had the chance to advance. This early discovery along with localized and systemic treatment altered the natural course of occult cancer before it progressed to a more advanced stage without symptoms. The result has been a reduction in PCa mortality.

    From the SEER database mortality table:
    1991-1994 the Annual Percentage Change (APC) was -0.5%
    1994-2005 the APC was –4.1%
    2005-2007 the APC was -2.6%

    As you can see from these numbers there is still a reduction in mortality in a population exposed to “widespread” use of PSA even when there is major opposition to its use and men at 75 or older are not recommended to have the test. When will the experts recognize that PSA is a current tool to avoid dying from PCa? Don’t blame the tool; blame those that misuse it!

  11. Ralph:

    As you well know, I have never disagreed with you that use of the PSA test has significantly contributed to the reduction in numbers of men being diagnosed with advanced disease and to the numbers of men dying of metastatic prostate cancer. I am NOT blaming the tool. I think the PSA test — for what it is — is extremely valuable.

    You are absolutely correct. It needs to be appropriately used. And it isn’t. I have previously outlined a potential appropriate use strategy, which would allow for baseline PSA testing followed by appropriately tailored use of the test. Such a strategy needs to be tested.

    The problem is that people use the term “screening” inappropriately (because it is a population-based testing strategy, not an individual one) and many in the prostate cancer community still believe — along with Reuven — that every man in America over 40 should get a PSA test every single year (a true “screening” strategy). There are no data whatsoever to support such thinking, which was the only point I was originally trying to make to Reuven, who promptly put words in my mouth that I had never uttered. What annual PSA testing leads to today (again because of poorly thought out behaviors on the part of many doctors and many patients too) is significant over-treatment and a completely unknown impact on mortality compared to the situation 10 to 20 years ago.

    As Tony Crispino regularly points out, there is little point to making decisions about the management of a disorder that takes 20 years to reach meaningful endpoints when all one has is 5- or 10-year data … but we keep doing this.

    I would prefer it if we stopped using the word “screening” altogether in reference to prostate cancer and the PSA test for the simple reason that it is an insufficiently specific test. It is a test for possible risk of prostate cancer and not a test for prostate cancer at all. We still need a much better test.

  12. Mike,

    In order to have a productive conversation I think we need to define what “screening” means and how we want to use PSA testing.

    I think there is complete agreement among those on this thread that PSA helps reduce prostate cancer mortality by diagnosing it at an early stage.

    I would suggest we stop using this charged word — “screening” and decide on the process:

    (a) Baseline PSA test at an early age, probably based on family history, ethnicity, etc.
    (b) Regular PSA testing based on the results of the baseline test and adjusted to age

    I will leave the discussion on the best baseline age and frequency for later.

    The big concern is that when men read that PSA screening should not be instituted, the interpretation of many is that they should not be tested. The prostate cancer advocacy community should mobilize against such a position.

    Let us remember that the ACS’s position was also to oppose mammograms. They changed this position in face of the women’s groups strong reaction.

  13. Reuven:

    I am more than happy to “dump” the word “screening.”

    I would not agree with the precise process you are suggesting because it is arguable that everyone should at least consider getting a baseline PSA. (The value of this is indicated by g8rb885’s earlier comment in this discussion.) It is certainly the case that some men need to clearly take issues like ethnicity and family history into account in deciding exactly when to get such a test.

    The Prostate Cancer Roundtable policy statement about testing for prostate cancer issued after publication of the data from the PLCO and ERSCP data in early 2009, reads as follows:

    — “Every man, regardless of his age, has the right to know whether he is at risk from prostate cancer, a disease that still kills over 28,600 American men every year, and many more around the world. We encourage all men to be proactive, and to seek out information and support in regard to their health.
    — “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. Further clinical action based on results of these tests is also a matter for serious discussion between each patient and his physicians.”

    There has been no change in that policy statement since that date. (You will note that it carefully avoided the use of the term “screening.”)

    To be fair to the ACS, they clearly disagreed (rightly or wrongly) with the USPSTF regarding mammography guidelines (see this ACS media release from 2009). That one is a politically charged bomb that makes the issue of appropriate PSA testing look easy by comparison.

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