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For an alternative to Peter Beattie’s simplistic advice on prostate cancer screening, listen to Dr Swan

In a column in The Weekend Australian earlier this month, the former Queensland Premier Peter Beattie described his personal experience of being screened for prostate cancer and encouraged other men to get tested.

“The real challenge is to get men to be tested,” he wrote.

The article concluded with the rallying call:

As I get older I hate the thought of getting prostate cancer. But I know my annual check-up, notwithstanding the affront to my dignity of the digital rectal examination, enables me to manage my fears and early detection can be the difference between life and death. It is an easy choice really.

Actually, it’s not an easy choice at all, and someone in Beattie’s position, of influence and with access to high quality information, should know better than to reduce such a complex health decision to a simplistic punchline.

For the sake of balance, and to give Croakey readers some idea of the complexities that men need to consider when deciding to have a prostate specific antigen or PSA screening test, here is an edited transcript of remarks made by health broadcaster Dr Norman Swan at the launch last November of this book, Let sleeping dogs lie? What men should know before getting tested for prostate cancer (which is freely available here.)

My perception of Norman Swan is as someone who is careful with his words, as you’d expect from a broadcaster, especially one who is forensic in his investigations of the evidence base of health care. He is not prone to hyperbole or dramatisation.

In my view, this makes the comments that follow below – suggesting that prostate cancer screening has led to “mutilating men unnecessarily” and as “a really dark moment in the history of medicine” – even more significant. This is an edited transcript and you can download his full remarks here.

(Note: For more of the back-story about the book itself see the bottom of the post)

Dr Norman Swan (edited transcript of remarks at University of Sydney on November 18)

“I am honoured to be in the presence of so many PSA refuseniks. I pay due honour to Alan Coates who led the way in refusing to have his test done (see bottom of post for further explanation).

I made the mistake of having it done once….I won’t tell you the story but it was not a pleasant story… It taught me the error of my ways.

…Australian urologists who are actually working in this field have changed their practice. The good ones have. They have slowed right down. If you go to a good urologist these days with a PSA of 4 or 5, they are not going to do what they did four or five years ago, which is jump in and rip out your prostate. They might want to, but they don’t do it. Many still are.

Practice has changed, practice is changing in the US, let’s not be overoptimistic about this.  It would not have changed had it not been for consumer pressure. Be under no illusions here whatsoever. It has not changed as a result of impact of evidence. It has changed because of the impact of public pressure.

You cannot go on with the practice that has been going on in this area – essentially mutilating men unnecessarily – without having a backlash.

And that backlash is beginning to be noticed by Australian urologists – still not, I’m afraid, by the prostate lobby but by urologists, I think it’s increasing.

Tom Stamey, whom as many of you would know, was one of the pioneers of using the prostate specific antigen as a screening test, came up with the idea at a level of PSA of 25. That’s what he was talking about – PSAs of 25.  These days sometimes you’re heading for a biopsy, sometimes with a PSA of over 2.5.

It’s become mad stuff. A lousy test, which at every step of the way the evidence is poor.

What is the number needed to treat? With current randomised controlled trial evidence. At five years, the number needed to treat is 48 men to have a radical prostatectomy for one man’s life to be saved over time.

That will improve over time. There is no question that men’s lives are being saved but at enormous cost.

So Tom Stamey has recanted…

The evidence from the NSW Cancer Council data is that 75 percent of men are still impotent at five years down the track. It’s probably not going to get a lot better if the Cancer Council gives the funding for extended followup…12 percent of men are incontinent and none of those men will know which of their lives have been saved as a result of their treatment.

This will go down in history as a really dark moment in the history of medicine when blunderbuss therapy has been used in an area where, at every step of the journey the evidence is either against it or…lousy

… It’s a really bad test overall. Probably age is a better measure of risk than your PSA test.

When you have a positive test and then they send you for biopsy, nobody actually knows the right way to do a biopsy: 8 punctures, 10 punctures? Some urologists will be doing 24. The more they do, the more likely they are to find a few rogue cells.

To be published on Monday is a paper from the United States, a cohort study which suggests the Gleason score is not a very good predictive score of outcome in localised prostate cancer. They’re probably wasting their time doing Gleason scores.

So every step of the way, the evidence is lousy.

We have private and public institutions around the world spending large sums of money on robots to do radical prostatectomies, with very little evidence that it does anything apart from get you out of hospital sooner…but many men and surgeons believing it is reducing complications such as erectile dysfunction and incontinence. But there is zippo evidence behind that.

Men need this information. ….

…This is not a book that says, ‘don’t have things done, it says have them done with your eyes open’.

…the first step if you take the patient’s journey; the first step is: am I going to have this test? A lot of the emphasis is on PSA…because once you have this test, you’re on the bus and it’s very hard to get off the bus.

The critical moment is: will I go and have this blood test done? And not enough men actually understand that.

I commend it to you all. Buy it…”

***

Some relevant back-story

Peter Beattie mentioned Federal Treasurer Wayne Swan four times in his article. Since his own treatment for prostate cancer, Wayne Swan has been a prominent advocate for prostate cancer screening.

Several years ago, he horrified many when he launched a vicious personal attack on former Cancer Council Australia CEO Professor Alan Coates, who had said he wouldn’t personally have a PSA test, questioned the evidence base for prostate cancer screening, and encouraged men to get informed and make up their own minds.

Wayne Swan responded on national television:

What Professor Coates just said is absolutely outrageous and rejected by 95 percent of urologists in this country and for that he ought to be removed from his current position because what he’s advocating is ignorance, not information. And what he will do, if that succeeds, is condemn many young men in this country to death.

You can watch his performance here.

[youtube]http://www.youtube.com/watch?v=edcosaTr03E[/youtube]

I wonder if Wayne Swan has ever come to regret those remarks.

I am sure Beattie could have found better sources than Wayne Swan to cite in his column.

Simon Chapman told the launch that Wayne Swan’s attack – watching Coates “being vilified, slandered, treated like pariah” – was one of the reasons he and his colleagues decided to do their book.

The country owes Coates “an enormous debt” for putting the issue of prostate cancer screening on the agenda for debate, Chapman added.

Coates, as Norman Swan alluded to, was at the launch, and received a round of applause from the crowd.

For previous Crikey/Croakey articles about the book, see this piece by Chapman and this previous Croakey post.

Comments 11

  1. Bogdanovist says:

    It’s tricky. I don’t know much about this issue, and that’s really the point. Can I trust a plausible sounding article I read on the internets, with lots of links to ponderous thing written by people with weighty titles in front of their name, ahead on my GP/urologist?

    Encouring men “to get informed and make up their own minds” sounds very sensible, but it’s precisely because people do this that we have low vaccine rates leading to infant deaths from previously (almost) extinct diseases, people buying expensive pumpkin seeds to cure cancer, wearing holograms on their wrists to ease arthritis, drinking distilled water to prevent migraines etc etc.

    Unless you’re a trained specialist in the area you simply cannot reasonably parse the over abundance of ‘information’ available on the internet in order to trump your doctor’s opinion.

    If there is a problem here with medical practice, the quacks have to sort it out ASAP, with ruthless oversight from the relevant regulatory agencies. But encouraging people to spend their nights ‘getting informed’ about their medical options by reading some blog will, on the balance, lead to far more harm to far more people than telling them to trust their doctor. The doctors don’t always get it right, but they get it right (or closer to ‘right’) than the collective ramblings on the blogosphere ever will.

    In this instance, you may well be correct, I really don’t know. But as a general principle it is a murderous path to follow suggesting that people can trust the internet better than medical consensus, as flawed as that can be.

  2. Shooba says:

    Bogdanovist. The short answer to your question is … yes. You should take the word of Simon Chapman and Norman Swan over the word of your GP/Urologist. The American Cancer Society, Cancer Research UK, Cancer Council Australia, the Australian Government and countless other bodies have all rejected the idea of screening for all men. It is simply bad public policy.

    Urologists are at the coalface, and see men with prostate cancer survive treatment after an early detection, so it is understandable that they feel that men should get tested. But what they cannot say for sure is that each of those men would have eventually died from that illness. In fact, on average, 48 men are unnecessarily treated for prostate cancer for every solitary man for whom treatment is lifesaving.

    GPs often order the PSA test out of habit or because they assume men want to know. This is a fault on their part and the good GPs will talk you through the issues first before ordering the test.

    Wayne Swan’s (shockingly rude) rant in the clip above is indicative of a serious problem – men using their own individual experiences to make up their minds about the wider issue. Would Wayne Swan have died without his treatment? Perhaps. But to advocate that all men be tested is irresponsible on his part. Often men in his situation form the hardline view that the test is infallible because the alternative (that they are now impotent/incontinent for no good reason) is too much to bear.

    In a nutshell, that is why the PCFA (formed under Mr Swan’s watch) and the urological society (as I said, at the coalface) are the only groups to still advocate PSA testing for all men.

    I would recommend you read Simon Chapman’s book (linked above). It is a very short and succinct weighing of the facts and evidence. Ultimately it shows that for an individual the choice should be there, but the test is so deeply flawed that it is simply dangerous to say that all men should be tested.

  3. db says:

    Bogdanovist wrote:
    “it is a murderous path to follow suggesting that people can trust the internet better than medical consensus”

    However here the item on the internet is noting but a window into a portion of the medical community which shows us there is not medical consensus on this issue.

    We’re not talking about a few people worried about vaccinating their kids but instead the head of Cancer Council Australia for a decade (Professor Alan Coates) and an experienced medical journalist that practised medicine as a specialist before working for the ABC (Dr Norman Swan). A book launch is a million miles away from “collective ramblings on the blogosphere”.

  4. Doctor Whom says:

    My father had prostate cancer. It wasn’t detected for years. It was possibly what eventually killed him.

    I get a PSA about each year or so. Occasionally I get a digit up my anus. (Stop sniggering in the back row – my doctor does it)

    I have no illusions that these will do anything but keep me in the know a bit.

    If I get a warning- I’ll have to think a lot. Then maybe act – maybe not.

    Screening for prostate cancer doesn’t make any sense.

    Screening for Bowel Cancer does.

    Trying to introduce evidence into policy decisions can get one’s head cut off. Or contract not renewed. I know.

  5. Leo Braun says:

    “The real challenge is to get men to be tested”! Anyone seeking to ascertain the viability of the conditional PSA tests bulk-billing ought to peruse 18-01-10 dated attachment received by me on 22-01-10 within the email dispatched from Canberra as a consequence of my complaint emailed to the Minister for Health on 15-11-09 … https://croakey.org/psa-screening-is-a-public-health-disaster-says-cancer-doc#comment-1622

  6. Bogdanovist says:

    @db I appreciate what you’re saying, however how does one, who is not an expert, distinguish from this claim of non-consensus within the medical establishment and the kinds of claims made (for instance) at http://www.avn.org.au? In both cases individuals with apparently suitable qualifications, who most of the general public are not familiar with, are held up as examples of non-consensus. In both cases their are books and book launches one could also point to as further ‘evidence’.

    How can who does not understand the details themselves tell the difference?

    Lets look at the PSA situation. Lets assume that PSA screening can certainly help some men, but on average will cause more harm than good due to the many more men it will harm without due cause. On this score screening would not be good public health policy, even if individual cases it may have helped, even to the point of saving lives.

    Now, lets apply the same logic to the idea of disseminating medical advice to men via the internet (including reccomendations to read books) as opposed to their GP/specialist. In some cases (PSA screening for instance) it may be of benefit, causing men to question their GPs advice and potentially avoid uneccessary mutilation. However, overall, the advice given by a GP/specialist is far better than that an untrained individual could obtain via the internet/books. So even though in some cases (such as this, for arguements sake) someone could choose a better option than their doctor, as long as they happened to have read the ‘correct’ advice, overall they are far more likely to come to harm by self assessment of their needs, with input from the internet/books than they are by trusting their doctor.

    By a consistent application of logic, you can see that unless the medical establishment is wildy and frequently wrong, then the best course of action is to advise that people trust their doctor. That isn’t to say this should not be discussed at all in a forum like this, however the take home message here is ‘listen to Doctor Swan’, whereas it really should be ‘raise your concerns with, but then listen to, your doctor’.

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