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.