PART 19 of My PC Adventure – see full story HERE>
Writing about prostates is a treacherous business.
Not only is the topic a medical, political and emotional minefield, but it seems almost everyone on the web suffuses their prose with enough passion to fuel an AA meeting.
There’s a hint of ideology in many a treatise, PR hiding behind innocent-looking blogsites, and fear, loathing and frustration at the absence of a sure way to determine a cancer patient’s prognosis without cutting into him and creating an unnecessary mess.
The elephant in the forum room is the question of screening.
The word is easily misunderstood by us newcomers to the debate.
I’ve been politely advised there is screening with a little “s” – that’s standard individual testing (PSA/digital) you can get your GP to do – and SCREENING!, with a capital “S”, a loaded meaning and an exclamation mark.
The latter is a government-funded, national, population-based campaign to convince every male above a certain age (that’s disputed, of course) he needs to be checked.
As far as I can find out, no country offers this seemingly commonsense service to its aging male citizens.
The reason is that the outcomes of mass screening may be “over-diagnosis” and “over-treatment”, a couple of overs with more googlies and bouncers than a cricket test.
With mass screening, according to official (and some medical) opinion, we would discover cancer in many more men, but there would be no sure way to decide what to do with them.
It would create unnecessary worry and/or unnecessary decisions to undergo risky and/or expensive treatment that could have unpleasant side effects like incontinence and/or impotence.
Nobody can with all certainty place men diagnosed with prostate cancer into one of two categories – those who should be treated and those who should be merely watched.
Men cannot be guaranteed to react to news of an early cancer diagnosis (the whole idea of Screening) with any certainty, either:
- some with aggressive cancer will be relieved to grab at treatment;
- some with non-aggressive cancer will want treatment anyway, because they don’t like the thought of a scary disease lurking within;
- others will be sanguine and able to wait;
- and others will say bugger the danger, I’m not going to risk losing “manliness” and my ability to procreate (or at least practise at it, like Bob Trimbole).
Some people ask why push for national screening when already more than half the population already seeks tests from GPs?
There may be a simple rejoinder to that – some macho Kiwi blokes won’t go near a doctor unless they’re already dying, and some sectors of society (Maori and Pacific islanders, for example) don’t habitually seek regular checkups.
What would Screening do to the worrying statistic that shows twice as many Maori prostate cancer patients die as Pakeha ones? Are breast and cervical cancer screening campaigns on TV being aimed specifically at Maori and PI because of this factor?
As the last couple of paragraphs demonstrate, prostate cancer has all the intricacies of a Shakespearean drama:
- It affects a part of the male anatomy beset with cultural, psychological and physical conundra.
- It comes in enough varieties to make diagnosis and prognosis uncertain, even after invasive treatment.
- It’s sneaky: it may remain benign for decades and still be harmless when its host dies.
- It’s dangerous, because sometimes it has no symptoms, and when it’s finally discovered it may have fled its capsule and be wreaking fatal havoc elsewhere.
- It’s common enough to warrant political intervention and commercial attention.
My blog about prostate cancer began as an attempt to use my professional career as a writer and journalist to describe in great detail what it’s like to be a patient. Nobody else seemed to be doing that here.
However, as I started to do research to ensure reasonable accuracy and usefulness, I discovered the traffic in prostate information on the internet is immense.
For instance, WordPress, which hosts this blog, lists 10,000 to 12,000 prostate blogs a day, and they’re constantly changing.
When I’m posting daily news updates about prostate cancer this blog rates on the first of the WordPress prostate blog pages, but a few days into my current holiday I noticed Prostablog had dropped back to the sixth page.
The blog has grown to include daily links to prostate news, a time-consuming job given an upsurge in the US debate following publication of a couple of long-term studies, as well as an excellent two-part series in the Wall Street Journal.
By contrast, interest in New Zealand is patchy.
In 2006/07, our parliament considered a 585-signature submission from Act MP Muriel Newman asking the health select committee to consider national screening.
It rejected the call and ever since bodies like the Ministry of Health and the Cancer Society have withdrawn to their “no national screening” positions.
In January this year, new National Government Minister of Health Tony Ryall told the Dominion Post that bringing down prostate cancer rates was a priority for the Government, and signalled he could consider overhauling the current guidelines.
“There is a divergence of medical opinion on screening, but from my reading of it, there is consensus that men and their GPs should be given all the information to make their own decisions.”
He said discussions were planned between his office, the Ministry of Health and the Cancer Standards Institute, but there has been no word since then.
Late last month the Ministry and the Cancer Society advised that they are currently looking at recent US developments, but the word is there is nothing there yet to warrant a change.
Media coverage in NZ is sporadic, and tends to centre on fund-raising campaigns like Movember and the Indian Ocean rowing race.
The Dominion Post published a prostate spread at the beginning of January that had doctors and the Prostate Foundation urging reconsideration of the official screening policy, but it was a time of year when many people are on holiday and probably missed it.
Only specialist magazine NZ Doctor seems to have noticed the US debate, and I’m the only one posting anything about it on the Prostate Foundation’s web forum.
We don’t seem to have active online discussion groups like those in the US. New Prostate Cancer Info-Link, for example, has dynamic group exchanges on aspects of the cancer worrying members.
It could be a double-edged sword if contributors relied on others’ non-medical observations, but that seems to be countered by the expert input from administrator Mike Scott and his medical colleagues.
It’s impossible for a doctor to cover everything that might happen following treatment and patients are wary of making constant calls, for fear of seeming a nuisance or neurotic. Putting a problem online quickly elicits comforting feedback.
The screening issue looms ubiquitously in the prostate blogosphere, but it’s hard to judge how NZers feel about it. Few people have voted in the Prostablog poll about whether we should have national screening.
Should we have it?
I’ve tried to avoid becoming a campaigner for anything, other than urging men to get the tests (both PSA and digital exam), but I am getting to a position (yet to be fully informed, I admit) on national Screening with a capital “S”.
It’s this: we should consider the American Urological Association’s latest suggestion to PSA-test all men aged around 40 to determine their baseline levels of prostate-specific antigens.
It would establish a database that could be used later to determine if a man’s PSA levels were changing at a rate beyond those associated with age.
It seems, from what I’ve read, that rate of change is a key indicator of risk, although Mike Scott at New Prostate Cancer Info-Link says even that (PSA velocity, it’s called) is not proven.
But if a man entering the riskier ages – after 50 – was to get a test and it showed clear elevation of his PSA levels compared to the baseline established in his test a decade or so before, there would be grounds for further exploration, perhaps more testing to see what’s happening to the velocity.
On present medical knowledge, this still is not a perfect solution: my version of prostate cancer, for example, didn’t show up in PSA tests at all (.77); and current diagnostic procedures (biopsy) still don’t give a total picture of whether a tumour is dangerous.
But think of the considerable advantages such a policy change would hold for the government and others who are wary of committing to Screening.
- Testing at 40 would not put any immediate strain on treatment resources (men rarely get prostate cancer before age 50),
- and by the time the first cohort entered the risk era (a decade later) medical science is bound to have a more accurate diagnostic tool (there is already talk of a simple urine test being close).
I say let’s lobby the Ministry of Health to consider this new option…and produce some very compelling reasons if they turn it down.
It looks like a solid mid-term solution to a politically treacherous dilemma.
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