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?
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.”