The headline screams out
“Kochie gets tested for prostate cancer ”
and viewers are told that
blokes are “boofheads” who should all get the bloodtest and the finger up the bum.
It makes sense doesn’t it ?
After all prostate cancer is the most common cancer that men get and is likely to be the third most commonly diagnosed cancer in 2017. After all diagnosing nearly 17,000 new cases of prostate cancer in Australia in 2017 must mean that we should hunt for this disease and eradicate it.
Or should we ?
There is no denying that Prostate cancer is a terrifying and common disease. Over 3,000 men died from the disease in 2017. A much larger number of men are being diagnosed with this disease yet do not have an aggressive fatal form of it.
At the end of 2012, there were 20,122 males living in Australia who had been diagnosed with prostate cancer that year, 94,114 males who had been diagnosed with prostate cancer in the previous 5 years (from 2008 to 2012) and 191,896 males who had been diagnosed with prostate cancer in the previous 31 years (from 1982 to 2012).
These numbers would be a success story if the men involved suffered no harm in the detection and management of their cancers but sadly that is not the case. They are instead the classical examples of a phenomena referred to in the scientific world as the “overdiagnosis” of a disease or condition. The vast majority of these men would never had known about their cancers nor suffered from it.
Prostate cancer is statistically clearly an old(er) man’s disease and dying from this disease is typically a thing old men do.
This trend does not change with more aggressive testing and detection protocols, Age-standardised mortality rates have stayed remarkably stable for nearly fifty years despite a surge in the known number of recorded cases of prostate cancer
The advice by some Healthcare Professionals (unfortunately with vested interests) and media personalities such as Kochie refers to the testing of asymptomatic men. This advice however flies in the face of the evidence and the guidelines since:
FOR EVERY 1000 MEN TESTED:
- Only two men, younger than 85 years of age will avoid death from prostate cancer
- Only two men, younger than 85 years of age will avoid the spread of their prostate cancer
- 87 men will have a false abnormal test leading to a biopsy that turns out to be normal
- 28 men will end up with complications from a biopsy requiring healthcare
- 28 men will be diagnosed with prostate cancer. Most of them would never have had any clinical symptoms or concerns from this disease and would have died a ripe old age from other causes without having this knowledge
- 25 men will undergo treatment of their cancer. Very costly treatment
- 10 of these men who undergo treatment will end up with permanent side effects such as impotence, incontinence or bowel problems. Some will die from heart attacks as a direct result of their treatment.
The data is clear and convincing and the recommendations by various leading medical bodies are very clear.
We as clinicians should offer evidence based decision support to our patients on this matter and to my mind the evidence as presented by the NHMRC, the RACGP and the Prostate Cancer Foundation of Australia is very clear on the lack of benefit of routine offering and doing screening tests for prostate cancer to asymptomatic men.
It is certainly worth having the discussion and there will always be the rare exceptions, such as people with a family history of prostate cancer, in whom careful consideration of all factors need to be considered but a blanket instruction to screen all men is simply WRONG !
It should also be noted that the current national guidelines does NOT include a Digital Rectal examination as part of the screening process for asymptomatic men (sorry Kochie – you can relax now !)
My personal approach would mirror the excellent approach followed by Dr Casey Parker – evidence based and in accordance with guidelines in the USA, UK, Canada, Australia, etc.
Curious readers would do well do read Dr Parker’s most excellent summary from a few months ago on this subject.
It might even behove a few of our ACT Urologists to review the information on this subject before tackling the subject again in the media or subjecting my patients to $10-15,000 out of pocket expenses for prostate cancer surgery