Over-reaction to Norrkoping data in New Zealand

A report in New Zealand’s Old Dominion Post would appear to typify a classic type of sad over-reaction to the results of the recent Norrkoping screening study (on which we commented last week).

The report quotes  Dr. Brian Cox, MB ChB, PhD, the director of the Hugh Adam cancer epidemiology unit at Otago University, as saying, “It’s becoming very, very clear that prostate cancer screening doesn’t appear to work.” On other web sites in New Zealand, such as the Otago Daily Times, Dr. Cox is reported to have “appealed to the Ministry of Health and Cancer Control … to take appropriate actions to stop testing men without the symptoms of the disease.”

The “New” Prostate Cancer InfoLink has consistently held a position that mass, population-based “screening” of all men for prostate cancer (particularly on an annual basis) is not justified by any available data. However, the idea that we should “stop testing men without the symptoms of the disease” is certifiably insane. This would return men to a time in the late 1980s when the majority of men diagnosed with prostate cancer had progressive disease at the time of diagnosis.

It is true, in our opinion, that expectations of PSA testing are overblown, and can and do result in many men with indolent prostate cancer receiving unneeded treatment. We desperately need to do a much better job of appropriate use of the PSA test among those men at the highest levels of risk for progressive forms of prostate cancer while simultaneously educating the male population about the risks associated with over-treatment and the values of active surveillance. However, if we throw the baby out with the bath water — as Dr. Cox is suggesting — we will be committing a significant group of men with curable forms of aggressive but localized prostate cancer to metastatic disease and (potentially) prostate cancer-specific mortality.

We agree with Dr. Cox that we need better tests than the PSA test … and we need such tests soon … but that is no reason to cast men at risk for prostate cancer into the outer darkness until such a test is available. In the meantime we need to be doing the best possible job with the tools that we have available — and the PSA tests is very certainly one of those tools.

New Zealand does not have a formally approved prostate cancer screening initiative; the PSA test is used by men in New Zealand (and their doctors) to assess their individual risk for prostate cancer (presumably based on the normal factors like race, family history, etc.). We would suggest to Dr. Cox that he use his stature to help to educate men in New Zealand (and their primary care physicians) when and how to use the PSA test appropriately, as opposed to just calling the media to set back male health care by 30 years! He clearly did not read at least one of the statements attributed to the lead author of the Norrkoping study.

Although Dr. Sandblom did indeed state that the results of the Norrkoping trial could not justify the use of mass, population-based prostate cancer screening, he also said, based on the structure and results of that trial, that: “I would thus not categorically advise against PSA testing based on an individual decision from a man who feels concern about prostate cancer.” [Bold italic type added for emphasis.] There is a sound middle ground available for those among us who don’t think that every man over 40 needs a PSA test every year — and it is not the simple opposite.

4 Responses

  1. From the NCCN’s Guidelines:

    “The current NCCN Guidelines recommend that at age 40, high-risk men begin annual PSA and prostate exams. All other men at age 40 should be offered a baseline PSA and prostate exams and, if their PSA is 1.0 ng/ml or greater, they should receive annual follow-ups. If their PSA is less than 1.0, the NCCN Guidelines recommend that these men be early detected again at age 45.”

    We should thank Dr. Sandblom for “not categorically advis[ing] against PSA testing based on an individual decision from a man who feels concern about prostate cancer.” However, this is still an irresponsible position that puts the burden on all men to educate themselves and specifically demand a PSA test.

    If we need to educate ourselves and demand a test, who needs doctors?

  2. Excellent article. Strong. Direct. I especially like and agree with the comment that it would be “certifiably insane” to stop testing men without evidence of the disease. The only indication that I had prostate cancer was when my PSA reading doubled. I subsequently had a biopsy with a Gleason reading of 8. After much thought, I opted for surgery. Five years later, I now have a penile prosthesis, I am almost continent, and I am healthy. I am alive. And life is very sweet. If my doctor had not regularly checked my PSA, I would very likely now be ill or perhaps dead.

  3. I am not surprised to read Dr. Cox’s reaction to the study. This is what we hear from those that ignore explaining the effects of limited testing with PSA on mortality. The Sandblom study treated more men with intent to cure in the control arm than in the screened arm …. Hmm, isn’t that interesting? But then to them improving the survival of “at most” a third of men is chicken feed ….

  4. I am concerned that this is the tip of an iceberg. I am beginning to see a movement that has cancer screening phasing out in many countries, especially where the governments pay the tabs. My prediction is that it will be determined that foregoing screening is a reasonable least cost alternative that has only some collateral damage.

    Sigh … As I continue to bang the drum on awareness and early detection my arms are getting tired and it’s starting to look futile ….

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