Unlike most diagnostic tests, the retrospectoscope is universally reliable, even in the hands of a journalist like myself.
With the benefit of the retrospectoscope, it now seems so obvious. What were we thinking, expecting that there suddenly would be miraculous clarity around the vexed issue of prostate cancer screening, just because some randomised controlled trials were underway?
As you may have heard, the long-awaited findings have been published – you can find some results from the US one here , and the European one here.
And it’s still not possible to find a simple answer for men (and their partners) who may be wondering whether to PSA or not. It all depends upon how the individual weighs up the potential risks of screening (which are considerable) against the potential benefits (which are questionable).
The only thing that seems clear is that the PSA test should not be done unless men have been given the opportunity to provide fully informed consent first.
As an aside, one of the interesting points from this interview by Norman Swan is that while men are focusing so much on their prostates, they may not be thinking about the other health problems which are far more likely to get them and about which they could be doing something useful.
So far I’ve only been applying the retrospectoscope to the questions of an individual patient. Equally important are the questions surrounding allocation of health resources.
We are spending a small fortune (not just dollars but also health professionals’ time) on the widespread use of a test (and its sequelae) for marginal, if any, health benefits.
Imagine if that money was being used to deliver interventions that could really make a difference, especially for those who could really stand to benefit, such as vulnerable kids and families. It’s odd that we’re willing to spend millions on tests and expensive treatments for some, but can’t, for example, manage to provide basic dental care to people who really need it – like Aboriginal kids.
End of rant from me – here are some more thoughts on the PSA controversy, from Sally Crossing, of Cancer Voices NSW:
“Cancer Voices NSW, like many others organisations in the cancer world, has been waiting with interest for the results of the two large, international randomised trials looking at PSA as a screening tool.
The PSA test is used widely in Australia as a test for prostate cancer, now the most diagnosed cancer among Australians, but not for screening, due to lack of solid evidence.
There is concern that PSA testing leads to over-diagnosis and over-treatment, particularly as treatment often leads to major on-going physical problems for men.
We have been waiting in the hope that the PSA screening, and even the PSA testing, controversy would be resolved by the results of the ERSPC (Europe) and the PLCO (USA) studies which were reported in last week’s, New England Journal of Medicine.
The NEJM’s Editorial expresses doubt that we know enough to change policy either way, as the new evidence (ERSPC) suggests that screening per se makes only a little difference to deaths. Our interest also relates to the ramification these outcomes may have for the screening of other cancers.
Value of the patient perspective
Cancer Voices must look at this from the cancer consumer view point- and particularly of the prostate cancer consumer – rather than that of researchers, epidemiologists, clinicians or health economists.
The big question for us is – how can the individual or his doctor, know if he falls into the “harm” category – over-diagnosis and possible over-treatment, or not?
We suggest this is still unanswerable. The “desperate dilemma” of treating or not treating remains, and few will be willing to do nothing.
We also suggest that few individual men will want to wait for their prostate cancer to develop more compelling symptoms, with consequent less chance of effective treatment and recovery.
What is of most interest to prostate cancer patients is years of survival and quality of life, whereas the studies’ endpoint is death.
What cancer consumers want is studies that focus on less harmful treatment, better diagnostic tests and better use of current tests and biopsies.
We call for continued and increased research into identifying which cancers are the ones which are likely to require treatment, and greater specialisation in prostate cancer surgery so that nerve-sparing procedures might become more successful.
We recognise the conundrums – the messages for screening policy, the cost-effectiveness of screening and / or testing, and the balance between benefits, survival and harms.
We especially ask that the consumer view is factored into the decision-making processes, from national policy right through to individual levels.”
Professor Chris Baggoley, Chief Executive, Australian Commission on Safety and Quality in Healthcare, sent in this comment: I remain confused about the benefits, or otherwise, for PSA testing and I am very much in the age group that needs to the simple answer you hope for in your piece. I’m not so sure that Norman Swan isn’t selling men short if he does believe that they can only focus on one thing at a time. We can cope with prevention of hypertension and heart disease at the same time as focussing on prostates. I think we can think about our prostates while running!
Just to be fair to Norman; he was not making the comment about men being overly distracted by their prostates. It was his interviewee, the author of the NEJM editorial, Dr Michael Barry from Harvard Medical School. His editorial is freely available at: http://content.nejm.org/cgi/content/full/360/13/1351
So..the confusion continues but the end point of both the recent sstudies appears to be that so-called screening finds more prostate cancers yet in finding those cancers early does little to reduce the risk of dying from the disease. But amongst the numerous comments following publication is the very surprising one from Dr Otis Brawley, the Chief Medical Officer of the American Cancer Society who said – of the data in the European study (in the New York Times): “The test is about 50 times more likely to ruin your life than it is to save your life”. Now, lets not forget that the American Cancer Society has over the years stubbornly supported PSA screening. They have been the only cancer society in the NGO sector in the western world to support the test. Does this mean they have re-considered? Or is Dr Brawley having a problem persuading his professional colleagues that the time has come to think again?
On PSA tests, having set this particular ball rolling and having read the many comments on Crikey/Croakey, I first want to thank all those who have contributed. What an amazingly broad set of comments they are! That breadth in itself is interesting – and useful.
Let me pick however on a couple of comments from Sally Crossing of Cancer Voices:
“The big question for us is – how can the individual or his doctor, know if he falls into the “harm” category – over-diagnosis and possible over-treatment, or not?” Seemingly no ‘big question’ about anxiety or about resource use?
“We also suggest that few individual men will want to wait for their prostate cancer to develop more compelling symptoms, with consequent less chance of effective treatment and recovery.” Maybe but how many ‘individual men’ sit around waiting and wondering if their cancer will develop? And if the PSA test did not exist how many fewer men would sit around waiting and wondering?
“What is of most interest to prostate cancer patients is years of survival and quality of life….?” Is it? Is this statement evidence based? For me yes both years of survival and quality of life matter but I note that here and in many other comments the question of anxiety gets missed or down played.
Sally goes on: “Cancer Voices must look at this from the cancer consumer view point- and particularly of the prostate cancer consumer – rather than that of researchers, epidemiologists, clinicians or health economists.” Yes that seems reasonable but then if I had never had a PSA test I wouldn’t have joined the ranks of the ‘prostate cancer consumers’. (In passing, PLEASE can we have some other terminology than ‘prostate cancer consumers’! This is not a market place with ‘consumers ‘ – or is it?)
My main beef originally was that I (and I suspected other men) were simply not being given the information necessary to make an informed rational decision. There are now fewer excuses for that to continue.
Can someone somewhere keep an eye on the number of PSA tests conducted before and after the publication of the results of these two studies? They must surely go down … surely!
On fee-for-service (FFS) medicine which I indicated worries me in this context and in others (how many PSA tests if there were no fee?), there is evidence that fee-for-service medicine leads to more activity. But Jon Hunt writes: “The problem with not using FFS is that it doesn’t matter how much work you do you get paid the same, so perhaps I should call in for a Monday sickie once in a while like everybody else.” Where has the professionalism of medicine gone – or is such professionalism just a silly old fashioned idea and is medicine now just another commodity like potato chips or another service like hair cuts?
And to finish: writing this in AIDS ravaged and poverty ravaged and inequality ravaged South Africa, the waste of resources (as Melissa Sweet acknowledges) on many unnecessary PSA tests is not just stunning but disturbingly unethical.