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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