My offer for a public debate was accepted after I co-published opposing viewpoints about the high rates of over-diagnosis and over-treatment of early stage prostate cancer with leading urologist Professor Tony Costello in a Melbourne newspaper last year.
The debate took place at a Melbourne conference on prostate cancer last week. It received wide coverage in newspapers – here, here and here, television radio, and online. All of this is useful and important because it helps stimulate the very important debate about widespread PSA screening.
Prostate specific antigen (PSA) is an enzyme secreted in large amounts by normal as well as cancerous prostate cells. Only small amounts of PSA leak into circulation from a normal prostate, but this increases with any prostatic disease, benign or malignant.
PSA concentration is expressed as a number and its discovery in 1983 led to it being used as a screening blood test for early prostate cancer. A level below four is considered normal and men with abnormal results are usually sent for biopsies. It has been widely performed in Australian men for over ten years as part of a general health check but its ability to save lives is now being assessed and tested.
Urologists are butchers, so GPs should stop prostate screening. Better that 1,000 die than 4,000 more get mutilated by urologists.
I would also point out that, in our age of government intervention in medicine, many of the decision makers are actuarially ignorant. As a man gets older, the odds of his living longer INCREASE. Using an online estimator, answering their questions, at my current age of 63, my life expectancy is 88. Changing nothing but my age to 73, my life expectancy jumps 4 years to 92. Refusing prostate screening because you are going to be dead in a few years is evil.
“First, kill all the lawyers. Then the urologists.” – GC
Whoa, ball fans! That’s pretty harsh Gc. Doctors arguing against general screening are doing so under the maxim of first, do no harm. If the ratio was anything like your 1 in 5 for lives saved I would agree with you but it is nothing like that. The problem is that we can demonstrate considerable harm done in loss of life quality and life years while not being able to demonstrate improvement. For those with familial history or elevated risk suggested by other factors (regardless of what they may be) then these are where PSA tests should be employed because they provide some peace of mind rather than elevated concern and there’s a reasonable possibility of improving mens’ health. Tests should be available to those who have concerns and those who have elevated risk likelihood but population-wide screening likely does general harm while targeted screening probably has merit.
“population-wide screening likely does general harm”
No one, ever, has been harmed by screening.
No, I disagree. Just the worry induced by false positives (of which there is a distressingly high proportion with PSA testing) constitutes “harm”. Then there’s the unnecessary and harmful surgeries induced by these positives…
GPs include PSA in routine blood tests and they do digital (really more analog) rectal exams.
No one is hurt.
If PSA is high, and/or prostate feels like a chin, they send them to the urologist. The alleged problem arises after the patient goes thru the urologist’s door. If there is a problem, it is with the urologist, not the screening. The emphasis should be on how the urologist handles the case; the problem is not with the screening.
Consider this from Dr. Dach’s website (he’s against regular screening):
“Granted mortality declines afterwards, from 33,000 per year to 24,000 per year, but at a huge cost. We have eradicated 10,000 advanced prostate cancer cases per year in return for a huge price paid in degrading the quality of life for 1 million men overdiagnosed and overtreated for insignificant disease.”
Notice he compares the “degraded” over the life of PSA testing, but gives benefit of only one year’s PSA testing.
By his numbers, PSA testing has save 200,000 lives.
Prostate cancer will kill 28,170 American men this year. 10-year survival rate for early detected (local) prostate is 99%. I’m getting tested.