oneworldtalk

SIMON CHAPMAN AND ALEXANDRA BARRATT

September 24, 2009 Comments 7

In 2003, Professor Alan Coates, then 58 and head of Cancer Council Australia, admitted he had not had, and wasn't planning to have, a test to see if he had prostate cancer. Wayne Swan, a prostate cancer survivor, called his statement "public policy vandalism".

Coates was not a lone heretic. While it would be rare to find a smoker working in cancer control, or any woman in the same field who had not had a Pap smear, many men who know much about the evidence on whether prostate testing saves lives have not been tested themselves.

A study in 2002 of male GPs in Victoria aged over 48 found less than half had been tested; many physicians choose to remain ignorant about whether they have the disease. What do they know that the Urological Society of Australia and New Zealand does not?

The society has recommended 40 as the age for men to consider having their first prostate-specific antigen test, or PSA, and for those in the top half of PSA levels to be considered higher risk and "monitored closely". Those with lower levels could have less frequent testing.

Earlier this year, results from a European trial involving 160,000 men aged 55-69 were published in the New England Journal of Medicine. Only some were given PSA tests. It showed that if you screen 1000 men, you will find 82 cases, and if you follow these men for an average of nine years, there will be 2.94 deaths. In 1000 unscreened men over the same period, 48 cases of prostate cancer will come to light by men presenting symptoms to their doctor. There will be 3.65 deaths. The difference between the two means, in short, testing saves 0.71 deaths per 1000 men over nine years.

Prostate cancer is a disease from which you are more likely to die very late in life. For elderly men - those over 84 - the death rate is 767 per 100,000 men, while for those aged 40 to 44 it is 0.3. This means there will be one death per year from prostate cancer in every 330,000 men aged 40-44, an age group the Urological Society now believes should be tested. The odds of any one man this age dying from the disease are nearly twice as poor as winning first prize in a lottery with 200,000 tickets.

By doing a PSA test on all these men and applying the proposed threshold, hundreds of thousands of men will now be considered higher risk and monitored closely for prostate cancer.

Autopsy studies show you can find prostate cancer in up to one-third of men of this age if you look hard enough for it. By finding all these cancers there is the potential for harm on a massive scale, because there are real and frequent risks associated with treatments for prostate cancer.

Getting a test result is just the beginning. When cancer is suspected following a PSA test, we know in Australia it is aggressively treated in younger men. The European trial showed that to save just one life from screening, an additional 48 men would need to be treated, and it was using a much higher threshold than is now proposed here. In other words, to save one life, 48 men would be treated who would not have died from the disease.

They are treated because our science is not advanced enough to know which of 49 men's lives will be saved by having their prostates removed. And the treatment is far from benign. According to a review last year by the US Preventive Services Taskforce, one year after surgically removing the prostate gland, 20 to 70 per cent of men have reduced erectile function, and 15 to 50 per cent have persisting urinary problems.

There is no evidence from trials to support the proposed new strategy, nor has the Urological Society commented on its cost-effectiveness. What are the costs of close monitoring of half the nation's men aged in their 40s? What health-care services are going to be cut to cover the additional costs? Or must the health budget be increased?

To make such recommendations without considering the potential to do harm to men and to the health-care budget is irresponsible.

Furthermore, urologists and the companies selling PSA tests stand to benefit from concern among men to be tested. In a recent letter to the Herald a man who had undergone prostate removal said he paid $15,000.

These facts are almost always absent from the advice given to men by the few agencies which are aggressively promoting screening.

Simon Chapman is a professor and Alexandra Barratt an associate professor in the school of public health at the University of Sydney.