Is ignorance bliss? What if this lack of knowledge affects a cancer diagnosis? In a recent ruling, an independent medical panel recommended that men stop getting the annual blood test that can reveal the incidence of prostate cancer. It was the panel’s opinion that the tests do more harm than good. As could be expected, not everyone agreed with this.
The controversial recommendation, offered by the United States Preventative Task Force, is based on five clinical trials and is predicted to dramatically change the care given to men 50 years and older. The panel suggested that healthy men should no longer routinely receive a P.S.A. (prostate specific antigen) blood test to screen for prostate cancer. Its reasoning was straight-forward: the test does not save lives and often leads to more tests and treatments that needlessly cause pain, impotence and incontinence.
Since this opinion seems counterintuitive to many in the medical field who strongly feel that any testing or screening that helps clarify a diagnosis – especially related to a disease as potentially dangerous as cancer – is valuable and even critical, this ruling is receiving much debate. At the risk of further inflammation, here are some factors to help men of a certain age decide whether they want to know the facts, or not.
The Most Common Cancer in Men
The federal agency that is charged with tracking diseases in the United States is the Center for Disease Control and Prevention (CDC) and it has this to say about prostate cancer in the U.S. “The prostate is part of the male reproductive system, and is located just below the bladder and in front of the rectum. It is about the size of a walnut. The job of the prostate is to produce fluid that makes up a part of semen.
Prostate cancer is the most common cancer in men regardless of race or ethnicity, but it is more common in some racial and ethnic groups. Prostate cancer is more common in African-American men than in Anglo men. It is less common in Hispanic, Asian, Pacific Islander, and Native American men than in Anglo men.
In the United States in 2007 (the most recent year for which numbers are available), 223,307 men developed prostate cancer, and 29,093 men died from the disease.
Among men in the United States, the number of new cases of prostate cancer has decreased significantly by 2.4% per year from 2000 to 2006. The number of deaths from prostate cancer has decreased significantly by 4.1% per year from 1994 to 2006.”
Men and Medicine: Not a Good Relationship
As a group, men are notoriously indifferent about their health. As such, one would assume that most men would eagerly accept this panel’s reccomendation to stop routinely testing for prostate cancer. According to research completed in 2000 by the Louis Harris firm, entitled “Out of Touch: American Men and the Health Care System,” unlike women, men tend to avoid the medical system. Facts from this study reveal a distinct bias of men against disease prevention and medical involvement:
(1) Many men are out of touch with the health care system and face barriers to care. One of four (24%) men did not see a physician in the year prior to the survey—three times the rate found for women (8%).
(2) 33 percent of men did not have a regular doctor to go to when they were sick or needed medical advice, compared with only 19 percent of women.
(3) Men’s irregular contact with doctors means they often do not receive any preventive care for potentially life-threatening conditions. More than half of all men did not have a physical exam or a blood cholesterol test in the past year.
(4) Six of 10 men age 50 or older were not screened for colon cancer, while four of 10 were not screened for prostate cancer in the past year. Roughly a third of these men had not been screened for either disease in the past five year.
(5) Men’s behaviors and reluctance to seek care place their health at risk. The survey finds that men tend to avoid seeking medical attention or delay getting care despite warning signs. When asked what they would do if they were in pain or feeling sick, one of four (24%) men said he would wait as long as possible before seeing a doctor and another 17 percent would wait at least a week.
(6) Physicians often fail to counsel their male patients during office visits. Men and their doctors often miss opportunities to discuss health concerns. Among men who recently visited a physician, few reported that they received counseling on ways to improve their health or to prevent illness or injury. Counseling rates were low even among men known to be poor health risks. For example, only two-thirds of smokers said that their doctor had discussed smoking with them.
As with many other gender-based differences, when it comes to medical care, men are definitely from Mars and women are from Venus. If this is true, one can safely speculate that the citizens of Venus are much healthier and live longer!
The Panel Has an Independent Review
Anticipating the fire-storm of controversy once their recommendations were released, the US Preventative Services Task Force hired medical experts at the Oregon Health Sciences University to independently review the evidence that served as the basis for the recommendation. The Oregon group identified five clinical that sought to assess whether men who got routine P.S.A. tests were less likely to die of prostate cancer than those who did not get the testing.
According to the March 2009 issue of the New England Journal of Medicine, one of the trials was conducted in the U.S. over seven years and followed 76,693 men ages 55 to 74, half of whom were given annual P.S.A. tests. Another trial, conducted in Europe, involved 182,000 men ages 50 to 74 from seven European countries who were given P.S.A. tests every four years.
The report of the American study found no benefit to prostate cancer screening. Those who got screened were far more likely to have prostate cancer detected, got more treatment for it and also were slightly more likely to die from prostate cancer than those in the control group. The European study revealed that men ages 55 to 69 who were screened saw a 20 percent reduction in mortality from prostate cancer, but because the total number of deaths in the study was so small the benefits of screening were also small. Across all ages studied, screening provided no benefit in the European study.
The basic problem with testing for prostate cancer comes from the tendency of men to confront and then defeat the disease. This aggressive attitude toward cancer is not strictly a masculine gender trait, but many men seem to see this condition as a life-or-death battle – which of course it is – and they take aggressive action which is often misguided.
The leader of the Oregon study group, Dr. Robert Chou, was quoted in the New York Times as saying, “The problem with screening for prostate cancer is that the vast majority of men who have cancer in their prostates will never be bothered by it. But once they know they have cancerous cells in their prostates, many men insist on aggressive treatment — including having their prostates removed or irradiated. Such treatments lead many to suffer impotence and incontinence for the rest of their lives. The idea that knowing you have a cancer isn’t always a good thing is a very difficult concept for many people,” he said.
The other side of this debate comes from urologists who test and treat men for the disease and pharmaceutical companies that manufacture the P.S.A tests and prostate cancer medicines. Their argument is succinct: prostate cancer deaths in the U.S. have steadily declined since P.S.A. testing began. Whether this is a result of the testing is open to yet another debate.
Some experts suggest that, rather than testing every man over the age of 50 for prostate cancer, it might be better to give P.S.A. tests to those groups who have a higher likelihood of contracting the disease. This would entail testing Afro-American men and those who have a family history of the disease.
To Test or Not to Test
The ethical question of whether to test for prostate cancer should give pause to every general practitioner and urologist. Ultimately, the P.S.A. test is not causing the debilitating side effects of treatment for prostate cancer. It’s a test.
The future of all medicine lies in the development of therapies that are completely non-invasive and genetically-based. This explains the excitement in the medical community about the mapping of the human genome. Until this genetic therapy is readily available, physicians who deal with testing and treatment of prostate cancer should simply remember their medical oath – Primum non nocere – First, do no harm.