Much of the discussion around health care reform, whether in Australia or the US, seems to be based upon an assumption that more medicine is better.
This recent article at The Drum by the ABC’s Michael Brissenden doesn’t quite get to the crux of the problems with the US system of “Cadillac care” (ie that a specialist-driven health system doesn’t deliver the best population health outcomes, quite apart from the costs involved).
Prostate cancer screening is an example of how too much medicine can be to the detriment of the public’s health, according to a Melbourne cancer specialist, Dr Ian Haines. He writes:
“The discovery of the Prostate Specific Antigen (PSA) test 40 years ago fostered the dream that early detection of prostate cancer would dramatically reduce the death rate from this leading killer of mature men.
In the ensuing 40 years, tens and probably hundreds of millions of men have had the blood test. A vast number of these men have been diagnosed with prostate cancer as a result of the test and have proceeded to have debilitating treatments such as radical prostatectomy or high-dose radiation with the frequent associated side-effects of life-long impotence and incontinence of urine. Current projections are that if we continue to screen for prostate cancer that almost 20% of men will ultimately be diagnosed with it.
These men were all led to believe that their early diagnosis and treatment, with all its associated suffering and side-effects, had saved their lives. Some were high-profile politicians, media figures and sports stars and wanted to share their incredible luck with the rest of us. The media and blogosphere has been bombarded by these people and their surgeons exhorting all males to have the test regularly in the belief that it may save lives. But after 40 years, despite the general belief that this test was improving public health overall, it had never been proven scientifically.
Unfortunately, the two large and definitive randomised clinical trials designed to properly assess whether this test (that many Australian men over 50 years old have had performed at least once) can significantly reduce the death rate from early prostate cancer were published in 2009 and have shown close to zero benefit for having the test (see here and here).
The results confirmed the long-held views of many clinicians that 85% of all prostate cancers are so low grade and slow-growing and indolent that they will not cause a problem to the patient even if he otherwise lives to a 100 years old. Patients with these cancers have been filling our x-ray departments, hospital beds, operating theatres and outpatient, GP and specialist waiting rooms for 40 years having biopsies and operations and then lifelong treatments and counselling for complications of their unnecessary treatments. Is it any wonder that our hospital beds and GP clinics are full to overflowing? And the first baby-boomers are still only 65 years old. What will it be like in 10 years?
Ok you say, all those traumatic and unnecessary biopsies and operations are acceptable “collateral damage” for those 85% if it means that we are curing some of the remaining 15% of men with the more aggressive and potentially lethal prostate cancer with our debilitating treatments.
Unfortunately it does not achieve that. Almost all of those 15% will still die of their cancer irrespective of how early it is diagnosed and how aggressively it is treated.
Overall, one of these two trials from the USA showed that no-one benefits from treatment of early PSA-detected prostate cancer and the other large European study showed that for every 48 men who have radical surgery for the disease, one will be prevented from dying of the cancer and 47 will have incurred no benefit but all the side-effects from the treatment.
Some, including many with a vested interest, will argue with the methodology in these trials or use emotive diversions such as “cadavers never complain of impotence” but the facts have changed and irrespective of what we used to hope and believe, we now have to accept that early diagnosis and treatment of prostate cancer is debilitating, both physically and emotionally, as well as very expensive and, most importantly, ineffective. The much awaited PIVOT (Prostate Intervention Versus Observation Trial) results may change that but as it now well past its potential early stopping points, that appears unlikely.
Ah! say some urologists, but the new (and much-hyped and very expensive) robotic surgery is more effective and has fewer side-effects. Unfortunately a major study from Harvard University in 2009 showed that even though the immediate post-operative course was less complicated, the major long-term side-effects such as impotence and incontinence were actually MORE frequent after ‘minimally invasive robotic surgery.’
In addition, more detailed and sophisticated assessments of patients before and after any radical prostate surgery have shown that the incidences of severe incontinence and impotence are actually far higher than previously believed, especially for men who had no pre-existing problems in these areas. The results discussed here have moved some academics to call for a radical change to how we screen for and treat prostate cancer.
Professor Anthony Zietman, a radiotherapist from Harvard University, wrote in an editorial in the Journal of Clinical Oncology in 2009 entitled “Evidence-based medicine, Conscience-based medicine, and the management of low-risk prostate cancer”:
Delayed treatment remains an option should the cancer ever prove the need. The evidence is mounting, the advocates of surveillance are finding their voice, and the economic incentives are changing. I am optimistic that we can break our cultural addiction to immediate treatment for all and move toward discriminating, selective, and more socially responsible behavior in this challenging disease. Sadly, it may take structural changes to our physician reimbursement system that currently incentivizes intervention and high technology before we see any substantial shift in practice patterns.
Professor Richard Ablin from Arizona University, the person who discovered PSA, wrote an op-ed in the New York Times on March 9, 2010: “The test’s popularity has led to a hugely expensive public health disaster… The test is hardly more effective than a coin toss. As I’ve been trying to make clear for many years now, P.S.A. testing can’t detect prostate cancer and, more important, it can’t distinguish between the two types of prostate cancer — the one that will kill you and the one that won’t. I never dreamed that my discovery four decades ago would lead to such a profit-driven public health disaster. The medical community must confront reality and stop the inappropriate use of PSA. screening. Doing so would save billions of dollars and rescue millions of men from unnecessary, debilitating treatments.”
He then asked: “So why is it still used? Because drug companies continue peddling the tests and advocacy groups push “prostate cancer awareness” by encouraging men to get screened. Shamefully, the American Urological Association still recommends screening, while the National Cancer Institute is vague on the issue, stating that the evidence is unclear”.
Regrettably, this sounds awfully like the position of our Australian Urological Society of Australia and New Zealand PSA testing policy 2009. In Australia, we even have “Movember” for a month every year to make sure no male avoids their “PSA punishment”.
I am yet to meet a urologist who has had a radical prostatectomy himself although there must be some somewhere. However, I do know that most oncologists I speak to will not have a PSA themselves. Fifteen years ago a relative of mine was very strongly advised by his urologist to have a radical prostatectomy for his biopsy-proven prostate cancer. With my advice and advocacy he declined. He is now on hormone therapy for a suspected isolated bone metastasis but remains very well, independent, continent and was, until commencing hormone therapy, sexually active and potent.
Regular PSA testing of otherwise asymptomatic Australian men has been a public health disaster that threatens to consume vastly more of our precious health dollars in the next twenty years. In the future, for the sake of Australian men and their families and our health system, I hope that more and more men will be given the correct information on PSA before agreeing to board ‘the PSA roller-coaster’ because it is extremely difficult to disembark once you are strapped in.
For many of those lured onto this roller-coaster, I hope that they will be offered the option of “watch and wait” if they are diagnosed with early prostate cancer in the future.”
• Dr Ian E Haines is a physician at Monash University at Cabrini Health, Malvern, Victoria