Prostate awareness month

is here.

Here’s an advert from their sponsors, Marks and Spencers.

You’ll note that it says “My husband had prostate cancer. He had no signs or symptoms. How were we going to cope?”
This sounds suspiciously like screening (although it may mean that he had no prostate signs or symptoms, but e.g. metastatic symptoms. I don’t know.) We know that screening for prostate cancer using PSA blood tests doesn’t work. Richard Albin, discoverer of PSA, has written that it’s no more effective than a coin toss. (There’s lots about this in my book.)  The last time I criticised the use of women as a means to PSA awareness, an editorial in ‘Prostate Cancer and Prostate Diseases‘ came back, saying “it is hard to see the harm in providing the public with more information ” – well, if it leads to more men being screened, it’s  hard to see that harm wouldn’t be created.

The problem with this advert is that, whether they intend to or not, they create fear that a symptom free person may have prostate cancer and that screening will help. The chief executive of the Prostate Cancer Charity told the Guardian in 2010 that “every man over 50 who doesn’t have symptoms of prostate cancer is entitled to ask his GP for a PSA test. Yet, 70% of men aged 50-70 don’t even know that the test exists, let alone their right to request it”.  Back to Albin, who writes from the US: ” Testing should absolutely not be deployed to screen the entire population of men over the age of 50, the outcome pushed by those who stand to profit. I never dreamed that my discovery four decades ago would lead to such a profit-driven public health disaster.” Of course, we have plenty of private clinics here in the UK pushing the screening agenda too.

I can only conclude that awareness campaigns are very bad for our health.

 

13 Responses to “Prostate awareness month”

  1. bill sutton March 4, 2012 at 11:32 am #

    I’m emailing simply as a lay person here, but surely if the PSA test picks up some incidences of prostate cancer, isn’t it worth doing? The success rate (in identifying prostate cancer) may be low, but it will have SOME success. I don’t understand your vehement objections to having the PSA test.

    rgds Bill

  2. Margaret McCartney
    margaretmccartney March 4, 2012 at 11:40 am #

    the problems are multiple. Screening for disease is complex; screening always does harm. The issue is usually the balance between harm and benefit. Prostate cancer is a spectrum – many men die with prostate cancer rather than from it. Studies looking at autopsy results have shown that prostate cancer is present in a large proportion of men who died from something quite separate. Treating all the prostate ‘cancers’ found on screening with surgery means that large amounts of men will endure the side effects of impotence and incontinence. Now, if that surgery has delayed your death, that might be a fair trade. But if that surgery was unnecessary, it’s a bad deal.
    The problem is that we are not often told about the hazards and problems of PSA screening, just made fearful of cancer. This isn’t helpful – a large section of my book is devoted to examining this – it’s bad for us. hope that helps.

  3. Derek Tunnicliffe March 4, 2012 at 5:48 pm #

    Thanks for that bit of reality, Margaret. My father died after a massive heart attack – with a prostate cancer that had been diagnosed ten years before (he had refused treatment). Another relative had a poor PSA, chose the operation offered and nothing was found. Fortunately he had no difficult side effects: except he now worries what was the cause of his high PSA – which still shows!

  4. bill sutton March 5, 2012 at 10:28 am #

    Margaret, thanks for your comments. I have a lot of American friends who point out to me that irrespective of any doubts there may be over the effectiveness of PSA testing, “the fact is” that mortality rates from prostate cancer are significantly lower in the USA than in the UK – and lower in the USA than in Western Europe, for that matter. Their argument, as you’d imagine, is that extensive PSA testing in the States does work. As a strong supporter of the NHS, how do I counter this argument? Why are mortality rates from prostate cancer higher in the UK than in the US? Are the international data comparisons missing something here?

    Bill

  5. steve March 5, 2012 at 4:32 pm #

    Keep up the good work Margaret. It’s a bit like the “detect cancer early” programme. I recently received an unsolicited flyer about this and wrote to them asking for the evidence.
    As an experienced GP with a strong interest in evidence based medicine I am looking for more information that demonstrates clearly that detecting cancer early actually significantly reduces death rates from these cancers as that will be the best way I can persuade my patients to adopt this strategy.

    To emphasise your own point about PSA testing, the evidence from the USA shows that the number of diagnoses of prostate cancer rose exponentially between 1975 and 1995 and although the numbers have fallen since then they are still 50% more than in 1975. Yet the death rate from prostate cancer has remained essentially static with only a slight fall in the last decade (well after the rise in diagnoses began – indeed after it had started to decline again – and probably due to newer treatments).

    Similarly the evidence for lung cancer in the USA shows higher death rates in those in whom we went looking for cancer as almost all with “suspicious” lesion underwent very risky surgery from which a number died. This seems crazy when we have no idea how any of these newly discovered lesions would have behaved. The famous Mayo Lung Study showed a persisting long-term increase in deaths in the screened group.

    You regularly highlight the breast screening controversy currently agitating people in the UK medical press and, again, it’s fair to say that mammography screening per se has failed to demonstrate a significant impact on reducing deaths from breast cancer (as opposed to the benefits of newer treatments) – the number of new diagnosis between 1975 and 1995 in the USA rose by nearly 70% but the death rate was largely unaltered.

    Similar cases can be made for melanoma (three fold increase in diagnoses, death rate unaltered) and thyroid cancer (two fold rise, death rate unaltered).

    One of the stated aims of the Detect Cancer Early Yes programme is “to work with GPs to promote referral or investigation at the earliest reasonable opportunity for patients who may be showing a suspicion of cancer whilst making the most efficient use of NHS resources and avoiding adverse impact on access”. But how, in practice, can these effectively mutually exclusive ideals be married?

    If we look harder for cancer we will, of course, find more cancer but we have no way of knowing which lesions would have caused harm if left undiscovered. But having found it we are compelled to act thus exposing our patients to all the physical and psychological traumas of unnecessary investigations and treatment.

    It has been argued that this programme isn’t just about mortality, it’s about improving length of survival. But, of course, if you find something earlier which is still going to kill you in the end your perceived “survival with cancer” will be longer.

    I have always thought that our poorer outcomes are down to two things – one you can do little about and that is genetics (I was very interested to see the report that came out of Glasgow recently which implied that much of the health differences between the poorest and most affluent suburbs of that city had a strong genetic element); the other is crap lifestyle and that is where we could make a really huge impact – if we could truly address the issues of poverty, poor diet, smoking, drug and alcohol misuse, lack of exercise, etc.
    Not easy I know.

    Meantime, I welcome any programme proven to detect cancer early and proven to show that this early detection results in reduced mortality and longer and better survival (on the basis that survival per se is not enough for me if it means an extra 6 month of dreadful life quality which is what we so often mean by cancer survival today).

    I am not against all screening as such and I fully support it where there is at least some reasonable evidence of benefit such as with colon or cervical cancer. But I need to see much more solid evidence before I can recommend that my patients sign up to “discovering cancer early”.

  6. Margaret McCartney
    margaretmccartney March 5, 2012 at 11:20 pm #

    thanks for these
    Bill, two issues –
    1) lead time bias
    2) overdiagnosis.
    Both make screening look better.
    With lead time bias, the destination is the same (time of death) but the diagnosis date is brought forward (screening vs symptomatic diagnosis.) So screening makes it look as though it increases lifespan, when it may not.
    2) Screening will pick up tumours that were never going to maim or kill. So if you diagnose lots of these, as long as the treatment doesn’t kill, it will make it look as though you can make more people survive longer. But these were people who weren’t going to die of the cancer in the first place. Again, screening looks better.

    Steve – I’m really concerned that the government are not distinguishing between early symptomatic diagnosis and screening. There is very little evidence that awareness campaigns improve outcomes and there is much concern that they increase inequalities. I think the money would be better spent on stopping an artificial 2 week wait/non urgent division and seeing everyone with symptoms more promptly. .. .

  7. bill sutton March 6, 2012 at 11:22 am #

    Margaret,
    I take your points about lead-time bias and overdiagnosis. If prostate cancer death rates in the US and the UK have indeed remained broadly stable for the past 2-3 decades this would certainly suggest that screening has little or no effect (apart from to distort the analysis).
    Of course, this begs the obvious question as to why prostate cancer death rates vary so much: e.g. the US rate is considerably lower than the UK, but Scandinavia is substantially higher. I would imagine that lifestyle, health differences etc. are unlikely to be significant factors (otherwise one would surely see Scandinavian death rates much lower than the USA?). My guess, therefore, is that genetics are the key. Or – I throw this question out – is it simply a matter of the reporting? We all die of something (and nobody seems to die of old age any more!). Is it possible, to put it crudely, that doctors in Sweden are more likely to put “prostate cancer” as cause of death than those in the USA?

    Bill

  8. steve March 6, 2012 at 3:15 pm #

    Bill – your last point may have hit the nail on the head. When I was a medical student in the 1980s there was a lot of hand wringing about why our rate of death from ischaemic heart disease was so much higher than Japan. Various theories were esposed such as their preference for a fish and seaweed diet, etc.
    But then it transpired that much of the evidence for a difference was not based on pathology reports but rather on death certification entries and that there was a cultural bias against putting ischaemic heart disease on Japanese certificates and a cultural bias in favour of it here in the UK.
    Now this is an anecdotal story but, at the very least, I think it holds an element of truth.
    To this day ischaemic heart disease is the fail safe entry as cause of death on UK certificates.

  9. AP March 6, 2012 at 3:42 pm #

    I seem to remember, at least in the good old days, that the sensitivity of the cervical smear was about 50-60%, so not far off a coin toss, and the specificity not that great either. Perhaps they just want to offer men the same opportunity to have false positives, and false negatives!

  10. Sarah Eades March 6, 2012 at 7:49 pm #

    Thank you for your hard work and interesting blogs. I’m close to finishing your book and found it fascinating. As an ex practice nurse a lot of the themes resonated with me and in fact I left because I was tired of QOF tick boxing which left time for other care of patients which was valued by them & me but not EMIS. Sorry to have gone a bit off topic here.

  11. bill sutton March 7, 2012 at 9:24 am #

    Steve,

    More on the reporting issue (and apologies, Margaret, for wandering off the subject) I understand that in the USA, autopsies are now a rare event, particularly compared to the 1970s. One of the unintended consequences is that “cause of death” is much less precise than 30-40 years ago. This leads one to question the validity of much of the data. Similarly, I have heard that much of the so-called success of the Mediterranean diet is down to French doctors’ unwillingness to diagnose heart disease as the cause of death.

    In economics – my field – international comparisons are notoriously unreliable for even the most basic data. In politically charged areas, such as the effectiveness of cancer screening, I would imagine the problem is even worse.

    Bill

  12. Chris Hiley March 11, 2012 at 4:32 pm #

    Hello M. Just bought your book. So must everyone else.

    Prostate cancer is perplexing and bothersome, much like the current Awareness Month. It’s difficult to argue against the good intentions of cancer charities but I always have a bloody good go. ‘Road to hell’ sums up the my conclusion on ‘good intentions’….. It’s important to point out the conflicts of interest of cancer charities – excellent with people with cancer but shockingly cynical when faced with the much larger group – the rest of us – without a cancer diagnosis but vulnerable through affected relatives and imagination.
    What IS prostate cancer awareness, anyway? It’s not a lifestyle related cancer, so there are no concrete risk reduction methods to employ (but improve your lifestyle any way, it’s good for the rest of your bod and it really makes no sense to come over all prostate aware, but f*** the rest of your body! That is not the sign of a successful awareness campaign in men’s health.) There are no early symptoms. The things that increase risk of prostate cancer you can’t change. Male, getting older, being Black. The cancer in its commonest form is not worth discovering and won’t kill. See the PSA debate above. The technology that will identify the ones that do kill does not yet exist. The PSA ‘screening’ test, beloved of all private providers and the crux of personal stories of men diagnosed through its use, because they ‘know’ it saved their life even when the stats indicate it won’t have, in most cases, since their life was not in danger. The PSA test is insufficiently specific as a gateway to early diagnosis for cancers that kill and the longer we hang onto it the longer it’ll take to get a teat that is. All charity campaigns really need a Call to Action to recommend as in breast screening (look where that got us), or to fuss over and cherish and prod men towards – the PSA test in prostate cancer.

    I read Bill’s musing on the much better mortality rates in the US and how that must be due to the PSA test. I wonder – was Bill actually looking at ‘survival’ instead? Not the same thing at all. This is where Rudy Giuliani famously went wrong in 2007 when putting his best American boot into the NHS, using the prostate cancer stats to back up his argument.
    Mortality is deaths. SEER data from the US for 2010 (most recent) says 24.4 per 100,000 is the current (age adjusted, all races) prostate cancer death rate in the US.
    It’s 23.7 per 100, 000 in the UK. Slightly lower mortality than the US, actually, though not hugely.
    Survival is a length of time – date-of-diagnosis to date-of-death. You can ‘increase’ survival by simply bringing forward the date of diagnosis. This apparent ‘survival’ increases even in the absence of any treatment, action or intervention against the cancer.
    5 year survival in the US is 99.4% – because the lead time bias from PSA testing is so huge. Here, it’s about 77%, which is the apparently worse difference that Giuliani latched on to as evidence that the NHS was awful. The US men survive five years after a prostate cancer diagnosis because they weren’t expected to die, not because there were more or better interventions. Or because the PSA test saved all their lives immediately.

  13. Bill March 12, 2012 at 4:17 pm #

    Chris,

    Actually I was indeed looking at mortality rates. I got the data from what looked like a reliable source – a website called “globocan”, which appears to be a WHO site. However, a quick back-of-the-envelope calculation tells me that these data are not age adjusted – which is a shockingly bad distortion of the statistics, don’t you think?

    I checked your figures (just to be double-sure!) and you’re absolutely right. Age-adjusted death rates in the USA and UK are essentially the same. Surely this destroys any argument in favour of PSA testing? (Though I’m sure some Americans will argue that mortality rates would really be much higher were it not for PSA testing. But I’d like to see some evidence for that notion!)

    Bill

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