Screening for illness is based on a simple concept: catch the disease early and more timely treatment will (inevitably) lead to better outcomes. However, as with most things in life, things turn out to be not a clear-cut as they sometimes seem. Tests are not foolproof, of course. And sometimes tests can detect things that don’t necessarily matter. For example, mammography will inevitably detect breast cancers that are not destined to significantly compromise the quality or quantity of the life of the woman in whom it has been detected. What this means in this case is that women may be subjected to unnecessary debilitating and expensive treatment. You can read more about the issues surrounding breast cancer screening here and here.
The male counterpart of mammography is the PSA (prostate specific antigen) test – levels of which can go up when the prostate is affected by cancer. This test has been enthusiastically embraced by the American medical community, while here in the UK doctors have been more reticent about deploying this test. This might have something to do with the fact that running PSA tests and the treatment that may result is a potentially lucrative practice in the context of ostensibly-private system of medicine in the US.
In fact, this fact has recently been highlighted a one Dr Richard Ablin. Today’s British Medical Journal contains a piece which explores Dr Ablin’s many objections to PSA screening [1]. In fact, he thinks doctors should stop using it, a view he expressed in a recent New York Times article. What qualifies Dr Ablin to take such a broadside regarding PSA? Well, he discovered it.
Some of Dr Ablin’s reservations about PSA screening are:
1. It is not specific for cancer: the cut-off point for PSA is generally set at 4 ng/ml. 80 per cent of men with PSA values of 4-10 ng/ml actually have benign (non-cancerous) prostatic enlargement.
2. Even when it detects actual cancer, the test cannot be used to determine whether the cancer is slow-growing and non-life-threatening or more aggressive in type.
3. Evidence shows that for one life to be saved as a result of PSA screening, 48 men would have to be treated. This leaves 47 men who have had perhaps non-critical surgery, that can leave them impotent and maybe incontinent.
This last point reminded me of a client I saw recently who had, some time ago, been found to have a raised PSA. Prostate biopsy revealed genuine cancer, and he was offered (with different specialists) different treatments of varying aggressiveness for this. In all of this, though, doing nothing did not appear to be an option.
However, he was particularly concerned about the potential side-effects of treatment, and resolved to do some reading and research. In the end he elected not to have any conventional treatment. He actually ended up consulting a naturally-oriented doctor with a special interest in cancer.
The last I heard his PSA was back down in the normal range, with no sign of any further advancement in his disease. He’s had no adverse side-effects either. At this stage at least, it appears his decision to do nothing (regarding conventional treatment) was the right one.
Dr Ablin is scathing in his opinion of what drives PSA screening in the US. In ths BMJ piece today he is quoted as saying “It seems to me that financial motives have spurred a tsunami of testing,” adding “There’s an unbelievable industry behind this. Unfortunately we don’t practise evidence based medicine here; we do things and later rationalise what we’ve done by saying we thought it was the best thing to do at the time.”
The piece ends with this quote from Dr Ablin: “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.” It’s one man’s view, but one that appears to be gaining considerable momentum.
References:
1. Hawkes N. Prostate screening: is the tide turning against the test? BMJ 2010;340:c1497
I understand the rationale behind Dr Ablin’s views, but I cannot agree. A routine medical identified elevated PSA in my husband. He was extremely fit, healthy and asymptomatic. Eventually, it transpired he had an aggressive prostate cancer. The prognosis was that without treatment he’d be dead within five years.
Because he was asympotamatic the PSA test may have saved his life.
Note the reference to ‘eventually’ in this patient’s history. The local consultant was unable to identify any cancer even after three sets of biopsies (he was looking in the wrong area). He also made little distinction between moderately elevated PSA and extremely elevated PSA (more likely to have a non-cancerous cause). The GP advised my husband to ignore the results. If he had followed this advice he would probably be dead.
My view is that the issue is that there is insufficient skill (lack of tyraining?) in interpreting PSA results and trends. Stopping the tests could cost lives.
How do you tell which PSA detected cancer is going to turn nasty and will kill you? How can the GP or Urologist reassure the man that he will die of something else before this ‘cancer’ that he has catches up with him. There seems to be an uncomfortable dilemma for all concerned.
Cybertiger
You’re right – it’s a tough call. However, my personal view is that these issues need open discussion, and individuals need to be made more aware of the limitations of PSA testing, as well as the potential hazards associated with having this test.
There are no easy answers, but doctors should not shy away from having frank, informed discussions with their patients about the pros and cons of screening.
@Mary S
You’re letting your experience with the situation cloud what should be proper public health policy.
What happened to your husband is immaterial: The reality seems to be his survival may have required unnecessary surgeries on > 40 other men.
Everyone in every field needs more training, errors are rife in any industry you carefully look at. More training isn’t going to happen, no money, no motivation.
Chris
On the big business with cancer I remember reading somewhere that if a cure were found tomorrow for all cancers that the world economy would fail over night! So big has this industry gotten that people make decisions driven by fear rather than on any evidence of successful or failed treatments.
@Helen
You should check out Gerson Therapy and first hand of someone who is on the therapy http://www.thewellnesswarrior.com.au – there is a cure for cancer, but it is hard work for the patient and no one is making big money from it (compared to drug companies)