Comments on: More than meets the eye in prostate cancer screening

By: dermot

dermot — Thu, 01 Jan 1970 10:00:00 +0000

guys! be calm!

thank you melissa the checklists referenced onthe ottawa site are very good. I have PSA tests done but I am in the age group early 50’s have form for that type of cancer on both sides of my family. If you are worried talk to your doctor about risk factors.

By: The Dark Lord

The Dark Lord — Thu, 01 Jan 1970 10:00:00 +0000

wow Pat & Neil… where did you get your medical degrees from? Statistics can be used in many ways but rarely for the greater good. Nice of you to mention that only 45% of doctors have had a PSA test… i suppose i have to go and read the article to see if you have quoted that figure correctly and in context - shame on you: not having the courage to qualify your claim… how many of the doctors in the survey were less than 50 years of age? i don’t expect you felt it relevant to note this, nor where the study was conducted, oh and did i forget to mention the study is 6 years old!!! So what is the evidence to support you claim Pat, that nearly all female doctors have had mammograms and pap smears.. please… back it up with hard data.
Now Neil, i am ashamed. It’s clear you don’t really understand the concept of screening do you… your patient - sitting across from you - sent in by their wives (who have probably had a mammogram or pap smear according to Pat) is not being screened. Screening is a population or community based programme of disease detection. What you do in your practice is case finding. Now this may sound trite or semantic but it is an absolutely critical differentiation. I agree, screening has not been shown to have an impact on prostate cancer survival rates. But case finding is a totally different issue. Are you able to categorically exclude prostate cancer in any man who presents to you? How? I know i can’t. If he is 48 and worried, are you going to send him on his way with an unknown PSA and without doing a rectal exam… what if he has a rectal mass without symptoms or a small high grade prostate cancer that is just palpable. You are not committing him to a death sentence by doing his PSA are you. You are assessing his risk of the disease… just as you do when you convince them to leave without a PSA test form… ignorant and happy… except with information like a PSA, he can be a little better informed himself. Shame on you to deny him that.

By: Neil

Neil — Thu, 01 Jan 1970 10:00:00 +0000

I may have to eat humble pie after the two big studies come out but never has there been a screening test searching for a disease quite like prostate cancer. I will declare my conflict of interest early on in that I am a GP. The advocates of prostate screening would have me stick my finger into the worried well as well as request a prostate specific antigen (PSA) blood test. My problem is the science doesn't back the screening for prostate cancer and I have see lots of old men living with the disease and not dying from it. I also see quite a few men faced with microcancers having major treatments such as radical prostatectomies and radiation of the prostate. Once diagnosed not many people can sit about and do nothing. Ignorance is bliss in this case.

In the past fortnight I have discussed prostate cancer screening half a dozen times with men. By and large they have been sent in by their wives. Most have been quite happy to leave unscreened and most seem to understand the concept of screening.

As far as the rectal exam goes, nobody likes it but nobody refuses it when needed.

By: bill

bill — Thu, 01 Jan 1970 10:00:00 +0000

I have been on the PSA testing circus due to an infection. After several PSAs and "high" results, biopsy. Negative. More PSAs, another biopsy ( less painful than the first). Negative. By now, my ?Benign Prostatatic Hyperplasia has gotten to a serious point. Had the TURP done. All pathology negative on 32 samples. My surgeon, managing me through this peroid out does not recommend PSA testing. I am in the business (biotech) of biomarker discovery (not for prostate cancer).

So with all that history, I start looking at "prostate specific antigen" - PSA and find - an old test with several manufacturers (is there is difference there already?) "Specific" is loosely used here. What do we have in current practice? A range of PSA test kits from different manufacturers , and a test where a "once off" is potentially very stressful if the result is high. A best it is only useful if a series of tests are done over time. What we need is specific test that looks for a biomarker that is proven to be associated with cancer, not something with that circulates naturally throughout the man's life. And that's what we have now, and that's one reason why there is no consensus of opinion about screening.

As for being lectured to by an over zealous GP and she failing to even explain what the PSA test does is just wrong.

By: Pat

Pat — Thu, 01 Jan 1970 10:00:00 +0000

Thanks Melissa & the Cancer Council for reminding us that no major evidence based agency anywhere in the world supports prostate cancer screening. This simple-minded stuff about it all being about embarrassment and not being a “man” is so peurile. The reason why no major agency supports it is because there’s no evidence that it saves lives comapred to men who havenlt been screened: as many have pointed out before, screening finds a lot of cancers that would have never caused trouble and the man would have lived a natural life span. But when they are found, there is a high probability that the medical interventions that then arise WILL cause big trouble in the incontinence and impotence departments.
An interesting fact is that less than half (45%) of male doctors have even had the test themselves (see Knowledge, attitudes and experience associated with testing for prostate cancer: a comparison between male doctors and men in the community. Intern Med J. 2002 May-Jun;32(5-6):215-23.) I bet nearly all female doctors have had mammograms and pap smears, and doctors have the lowest smoking rates of all. Doctors, who can read the evidence, know more than most about what’ screening tests are sensible.

By: Pat

Pat — Thu, 01 Jan 1970 10:00:00 +0000

Dark Lord, the study showing only 45% of doctors have had PSAs, surveyed drs aged >49 years, so thank you doctor, your highness, for your pompous, patronising attitude. [and BTW, where is YOUR evidence for your implied claim that 6 years later, these rates would have gone up substantially?] The distinction you try to draw between screening and case-finding is utter sophistry. The current and past campaigns trying to urge all men >50 to get tested are identical to campaigns designed to get women tested for breast & cervix cancer. It is nothing but screening by stealth.

The European Randomized Study of Screening for Prostate Cancer showed with yearly or even 4-yearly PSA screening, 48%–56% of cancers found would never have been diagnosed in the absence of screening. In other words, over half of the cancers detected by efforts designed to "case find" in asymptomatic men are indolent, low-grade cancers that would have not affected health or life expectancy. Men would have died with them, not from them - see Draisma G, Boer R, Otto SJ, et al. Lead times and overdetection due to prostate-specific antigen screening: estimates from the European Randomized Study of Screening for Prostate Cancer. J Natl Cancer Inst 2003; 95: 868-878.

So when screening enthusiasts like you get on your soapbox , you are driving demand for a procedure which will cause many men to undergo unnecessary investigation and often unnecessary surgery. A follow-up study of men undergoing radical prostatectomy reported that, after 5 years, 14%–16% of men had urinary incontinence, and 79% had erections insufficient for intercourse. (see:Potosky AL, Davis WW, Hoffman RM. Five-year outcomes after prostatectomy or radiotherapy for prostate cancer: the Prostate Cancer Outcomes Study. J Natl Cancer Inst 2004; 96: 1358-1367.) Odd that we haven't heard Michael Caton mentioning these important facts.

By: Lisa

Lisa — Thu, 01 Jan 1970 10:00:00 +0000

Finally “men’s problems” are being brought out into the open! Thank you to Dr Cumpston and all those in the medical profession who are trying to galvanise everyone into considering a change of attitude to prostate cancer checking/testing. Thanks Melissa for reminding us of the need for transparency…Ultimately, we all need to acknowledge the disease exists; diagnosis is merely the first step and, hopefully, all initiatives such as this will generate further research and lead to more refined diagnostics and treatment. It is every patient’s right to be diagnosed, and it is every GP or specialists’s obligation to provide it. Bring on more debate, and let’s get some answers!