Screening for prostate cancer – an old argument revisited

Links to material quoted are given fully at the end of this post.

Gee! It's almost two years since your Grumpy Old Journo – also known as a Happy Prostate Cancer Survivor – put up some posts disagreeing with Simon Chapman, a strong opponent of screening for prostate cancer. On November 6, 2007, I said:

Gee! Me against the Professor of Public Health at the University of Sydney. This should be a one-sided debate. But here goes.

If you've dipped into this blog over the past year or so, you'll know I'm passionate in urging mature men to ask their doctor for a prostate cancer check.

And although I've read Professor Chapman's article in Monday's Sydney Morning Herald [November 5, 2007, headed “Prostate screening not worth it”] – and was already familiar with the arguments he has put – I will not change my advocacy.

I went on to explain:

The reason is simple. Early detection of prostate cancer, before any symptoms became apparent, may have saved my life. At the very least, it saved me from having to make decisions about more risky treatment of an aggressive cancer after it had spread further. I hope you'll bear with me.

I'm trying to explain that screening is worthwhile for most mature men, provided the guy (and his wife and friends) understand its limitations.

All treatment options – including non-treatment, ranging from "watchful waiting" to "no point
worrying about it at your age" – have risks and shortcomings. What's the right treatment for one guy might be ill-advised for the next.

So now, almost two years later, Professor Chapman, in an article jointly authored by a colleague, Associate Professor Alexandra Barratt, has returned to the SMH's pages to reiterate opposition to screening.

Under the heading, “Irresponsible prostate proposal ignores risk of harm to men”, the professors attacked last Wednesday's call by the Urological Society of Australia and New Zealand for men to have prostate cancer tests at age 40 instead of the previously recommended age of 50.

The professors' argument, basically, is that studies show screening fails to save many more lives despite higher costs to the public health budget. They ask:

What are the costs of close monitoring of half the nation's men aged in their 40s? What health-care services are going to be cut to cover the additional costs? Or must the health care budget be increased?

Cost-effectiveness? The Urological Society's recommendation means that men should ask their family doctor to order a blood test for PSA – prostate specific antigen – and to do a digital rectal examination at age 40.

Most guys should have a general medical check-up around that age, involving heart, blood pressure and blood testing of cholesterol, so why shouldn't they also ask for a prostate cancer check?

Apart from the pathologist's charge for the PSA test, where's the significant extra cost? And close monitoring? That will only happen if your doctor believes your PSA or DRE results are a cause for concern – and brother, if your doctor thinks that, won't you be glad you asked for the test?

“Risk of harm to men” are the words in the heading. This refers both to the risks involved in a biopsy, and to possible over-aggressive surgery or radiation treatment when cancer is found.

But my experience is that despite the risk of infection from a biopsy, it's worth that risk because it will allow your urologist to avoid aggressive treatment if it's not needed. For some men the biopsy may show there's no need to begin treatment, but to accept "watchful waiting" with PSA tests from time to time.

It would be unproductive to run a longer post arguing my position. The following links should help anyone seeking more understanding of the debate.

My November 2007 post outlined my arguments at length – indeed, it was so long I followed with an “executive summary”.

Last Wednesday, the Urological Society published its new policy here and also issued this media release.

The next day, professors Chapman and Barratt had their article published in the SMH. And here's Professor Chapman's SMH article published in November '07.

Last week, the SMH published letters contesting the professors' views on Friday (including a letter from Urological Society president Dr David Malouf denying the society advocated a screening program, instead saying it recommended 40-year-old men "should be offered a prostate cancer test to assess their risk") and another letter yesterday (on each of these letters pages you'll need to read down a way to find the relevant letters).

You'll also find a good explanation of prostate cancer and its treatment options in Wikipedia.

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Me and my prostate: An executive summary

Sometimes you can get too close to a topic. And that's what happened in my earlier post, the one which follows this.

I've been tossing around since the early hours wondering what to do about it. Surely it's too long? Does it say far more about my prostate than you really want to know? Is it boring?

And worse, does it fail to drive home arguments I believe to be important?

Yes, yes, yes and yes! Then, about 4am, the answer came to me. What I need is an executive summary.

So here's a first from Grumpy Old Journo. An executive summary:

• Professor Simon Chapman, and many other researchers, believe prostate cancer screening isn't worthwhile.
• The initial screening is unreliable. If abnormalities are found, the patient must have a biopsy to confirm diagnosis, and the biopsy procedure itself carries risks.
• Even if a man has prostate cancer, he's probably going to die of something else first. Many men have prostate cancer when they die, but they've never had symptoms and it's not what killed them.
• Treatment may end the patient's sex life and leave him wearing incontinence pads. Even if it does extend his life – and that's uncertain – his quality of life may be diminished.
• However, screening may become valuable if better screening tests can be developed.

Against that, I'd like to put a counter-argument based on my experience and my reading:

• Despite their shortcomings, screening tests can indicate prostate cancer.
• Follow-up biopsies do carry risks of infection and some pain, but they are valuable, not only in confirming a cancer diagnosis, but in calculating the aggressiveness of the cancer – is it likely to spread into lymph nodes and pelvic bones?
• With this information, a guy (and his wife) can make sensible decisions about treatment options, including the option of no treatment. All specialists will explain the pros and cons
  of treatment they suggest and will offer booklets which set out that advice.
• Professor Chapman's findings are based on statistical analysis of thousands of men. With sound evidence, good advice and sensible decisions, a guy could beat the odds.
• Screening is the first step on the path which may lead you to a better outcome.

Jesus wasn't talking about the prostate health of his listeners, of course, but you might find his words of value when you think about screening:

"You shall know the truth, and the truth will set you free" [John 8:32]

I've got the following links at the end of the next post, but to save your time, here they are again: Professor Chapman's article in the Sydney Morning Herald, and a long, detailed Wikipedia entry.