Brochures encouraging men to talk to their GPs about prostate cancer have been attacked in prominent international medical journals, and New Zealand experts claim they are “taking a gamble with men’s health”.
Differing Opinions in the medical world
Invasive PSA testing, the most commonly used tool for detecting prostate cancer, caused an international health controversy in 2011 after a leading United States Government task force found the test did not save lives and caused more harm than good. PSA testing can lead to the unnecessary treatment of non-lethal cancer and leave men impotent and incontinent.
The debate has now flared up in New Zealand after the ministry kick-started a $4.3 million prostate cancer awareness programme and posted out booklets, brochures and posters to every general practice in the country late last year.
It is encouraging to see a 4.3 million dollar investment in men’s health but
Critics claim the information does not lay out the risks of testing.
Wellington GP Chris Kalderimis said he threw the brochures away and contacted his Primary Health Organisation and medical college to complain about them.
University of Otago cancer epidemiologist Brian Cox has labelled the resources “the poorest information packs sent out by the ministry in a very long time”.
The Prostate Cancer Foundation says the pamphlets are perfectly balanced and has branded the critics “pathetic”.
It was backed by Rodney Studd, a urologist based at Wakefield Hospital, who also believed the ministry information was balanced.
Now I’m confused – anyone seen one of these brochures?
“You want to treat men who are young enough to benefit, not old crumbly men.”
… and can someone please tell me at what age one becomes a ‘crumbly old man’
There was me thinking, as long as you didn’t feel a hand on each shoulder, you were safe!
Wellington GP Chris Kalderimis is a twit who should shut up.
A PSA test is hardly “invasive”. It’s a frigging blood test. And the “risks” with that are what ? Bleeding to death ? Give me a break !
A PSA test doesn’t tell a man has cancer just like a mammogram doesn’t tell a woman she has cancer. There is no difference. What both tests tell you is that there may or may not be a reason to go further and have a biopsy.
Maybe Wellington GP Chris Kalderimis should start telling women not to get mammograms. Twit.
The problem with prostate screening is that the test is not very reliable. Some men will test negative but actually have the cancer.
But the worst danger is that a significant number of men will get a false positive. If they then get treated there is a high likelihood of permanent incontinence (leaky plumbing) and/or impotence (can’t get it up no more). This “risk” is significant, and would affect hundreds of men if everyone was screened.
Prostate cancer does not necessarily kill you; many more men die with it than from it. In general, the older you are the slower the cancer grows.
Men who have symptoms (pain, can’t piss properly etc), or with a family history of aggressive prostate cancer, should definitely talk to their GP about getting tested.
Some medics who make their money from testing and treating this disease are keen on testing, for obvious reasons.
It isn’t just a simple blood test either, you also need to get a “Digital Rectal Exam” (finger up bum).
There are well-established criteria for mass screening programs, and this one doesn’t meet it.
Last time I went for the warrant of fitness the Doc told me the PSA alone was reliable enough now and the finger was no longer considered necessary. (I’ve been doing annual check-ups for a few years now, so he has a history of my PSA levels)
Then again I may fit into the ‘crumbly on man category’.
My medical advisor says both tests are a waste of time for you.
If you do get an elevated PSA level what will you do? (considering the risks I outlined above).
OMG – I’m a crumbly old man!
Yes mamograms are a stupid waste of money just like PSA testing on a wide scale would be.
Mammograms and cervical smears are a political answer to a lobby group and make no economic sense and little medical sense either.
#6 Allan. Maybe that’s acceptable to the people who haven’t been diagnosed with cancer following a biopsy after either a mammogram or a PSA test …..
That golfa is the problem. For everyone whose cancer is caught earlier many others suffer impotence, emasculation etc. For mammography women are subjected to radiation on a three yearly cycle when there is little evidence of any additional benefit of more than 2 mammograms over a lifetime.
Screening is about population health and the benefit or detriment to all versus the possible benefit to a few.
Screening for prostate cancer is futile. It doesn’t save lives. It is being promoted in NZ by a group of surgeons with a financial interest the diagnosis and treatment of the disease.
The Cochrane Library summary states “Prostate cancer is one of the most prevalent forms of cancer in men worldwide. Screening for prostate cancer implies that diagnostic tests be performed in the absence of any symptoms or indications of disease. These tests include the digital rectal examination (DRE), the prostate-specific antigen (PSA) blood test and transrectal ultrasound (TRUS) guided biopsy. Screening aims to identify cancers at an early and treatable stage, therefore increasing the chances of successful treatment while also improving a patient’s future quality of life. This review identified five relevant studies, comprised of 341,342 participants in total. Two of the studies were assessed to be of low risk of bias, whilst the remaining three had more substantive methodological weaknesses. Meta-analysis of all five included studies demonstrated no statistically significant reduction in prostate cancer-specific mortality (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.86 to 1.17). Meta-analysis of the two low risk of bias studies indicated no significant reduction in prostate cancer-specific mortality (RR 0.96, 95% CI 0.70 to 1.30). Only one study included in this review (ERSPC) reported a significant 21% relative reduction (95% CI 31% to 8%) in prostate cancer-specific mortality in a pre-specified subgroup of men. These results were primarily driven by two countries within the ERSPC study that had very high prostate cancer mortality rates and unusually large reduction estimates. Among men aged 55 to 69 years in the ERSPC study, the study authors reported that 1055 men would need to be screened to prevent one additional death from prostate cancer during a median follow-up duration of 11 years. Harms included overdiagnosis and harms associated with overtreatment, including false-positive results for the PSA test, infection, bleeding, and pain associated with subsequent biopsy.”
So if I had raised blood pressure and failed my bus licence medical examination before having a rectal examination I would probably be worse off?
Screening programmes may not be worthwhile but that’s not what this post was about. It referred to criticism, even throwing away the materials, of an information campaign to raise awareness of prostate cancer, presumably including warning signs and what one might do when aware of symptoms. Why would anyone object to raising awareness, even when diagnosis and treatment is still imperfect? It’s about time that this major health problem for men received some fraction of the funding long provided for (mainly) women’s health. I have had two good friends who were diagnosed relatively young with prostate cancer, received treatment and have remained well as a result. Diagnosis and treatment can’t be totally irrelevant.
This awareness programme could fairly have been extended to provide free consultations to those men who report possible symptoms, rather than simply encouraging them to purchase the services of medical advisors.
But to object to any programme for prostate cancer at all, now that seems to be a male-hating position or at least an attempt to curry favour with feminists who of course believe only women’s needs deserve attention.
Prostatism (urination problems associated with enlarged prostate) is a significant health issue for men in our society.
Prostate cancer is not, apart from those few men who are afflicted by an aggressive cancer.
The literature provided was mixing these two issues as Man X Norton seems to do as well.
The important point is that men can address health issues themselves by lifestyle changes. More exercise, less sugars and refined carbohydrates, more vegetables, sufficient vitamin D, etc
#12 It’s only 600 men a year who die from Prostate Cancer, so who cares, right ….
golfa many men die with prostate cancer, few die because of prostate cancer.
There is a huge difference.
I have news for you golfa. Eventually we all die.
Everyone dies from something in the end.
More than 600 men die every year, the number from prostate cancer is relatively small.
In 2010 14,337 NZ men died, that is about 4% of male deaths. Govt data shows 589 died with cause of death being listed as prostate cancer.
The lifestyle changes that many others would endure as a result of raised PSA figures if widespread screening was the norm, as some urologists would advocate, would be far more significant.
Golfa in 2010 nearly 400 NZ men topped themselves.
I wonder how many more might have considered that if they were told they had prostate cancer and therefore had one more reason not to live?
Your support for more widespread screening may lead to suicide rates exceeding male deaths due to prostate cancer.
I see where you’re coming from.
It’s like a military policy of leave no man behind, but you might all die together.
Because feminists have chased the medical (leave no woman behind) there has been an inclination for men’s activists to pursue medical equivalents but it’s not really doing anything more than satisfying our sense of politico-financial equality.
Downunder is partly correct to observe:
But don’t forget that a mass screening programme and the vast increase in (unnecessary) treatment that would follow will make some people lots of money. So don’t be surprised by constant disinformation on this particular subject.
As activists, we should certainly be pushing for increased funding for male health issues, but the money should go where it is most likely to benefit men eg: stopping smoking, improving diets, increasing exercise. Many Maori and Pacifica men don’t even live long enough to get their pension.
I just took a quick look at the Heart Foundation website to look for the number of men who die each year from heart disease. It’s a bit off-topic for a discussion about prostate, but it seems they don’t think ‘Men’s Heart Disease’ is particularly important. Presumably there is no money to be made from it!
#14. If 589 is a “few” to you then it’s pointless continuing the discussion with you.
Spend an evening at a Prostate Cancer Support Group and tell all of the men there that PSA tests are a waste of time …..
yes 589 is a few compared with 14,337.
putting effort into lifestyle choices; exercise, less sugar, more vegetables, less stress would mean thousands of men have longer and more fullfiles lives. The biggest gains are to be made in these areas. Spending resources on prostate cancer is a luxury most of the 14,337 can’t afford the rest of us to invest.
The problem as described to me by a urologist is what if your PSA is raised. It might be because of bicycle riding or other injury (or nothing at all) and to tell you can have a biopsy which was described to me as like having a small microwave up your rectum. The biopsy takes several samples but there is no guarantee that even with a negative result that you don’t have cancer. To be safe you can ensure you decrease all your male hormones such that you can’t get it up any more. Incontinence is often a side effect as well.
Yes testing is indicated where there is a family history or the DRE (digital rectal exam) finds a nasty irregular shaped prostate but to suggest that PSA testing should be done for every man is just plain false economy and will produce false positives. That is the problem. Even the doctor who discovere the test says NZ would be mad to implement testing as you (and a bunch of urologists with vested interests) propose.
Here is what the American Cancer society says about PSA results
Factors affecting PSA
In relation to Digital Rectal Examination (DRE)
Going back to my comment at #3 if I continue to do PSA tests, I am only getting a substantial result if my PSA goes over 10.
Downunder unfortunately your information isn’t as easy to interpret as you imply.
IF you are having PSA tests then variations from one test to the next may be significant even if under 10.
Also to suggest that prostate cancer is a big problem is alarmist. Probably 40-50% of men over the age of 75 will have prostate cancer BUT this is normally not a big deal. They will live with it and die with it and although it may cause some visits to the loo during the night otherwise it is likely to be a minor factor in their overall health and eventual cause of death.
Cancers are not all equal. Lots of older men have prostate cancer and it causes them little effect. However the scary thing about prostate cancer is that when it appears in younger men it can be aggressive and life threatening.
What Golfa and some others above don’t seem to appreciate is that raised PSA tests and prostate cancer need to be viewed based on age, lifestyle, expectations, life expectancy, and other health issues for each person individually. Yes prostate cancer can be hugely significant and a big deal for some men. Those are the ones who need to be having regular monitoring with PSA and DRE.
Unfortunately Golfa seems to feel that every man should be having such tests and that would be bad for the health of many, expensive with unnecessary biopsy’s and would negatively effect the physical, emotional and mental health of many individuals when there is nothing for them to worry about.
Those who have been diagnosed and successfully treated for prostate cancer will have a very different opinion from the self-appointed experts in this thread who minimize the signficance of this cancer and who seem to be discouraging any attention to it. These men, including some prostate cancer survivors, certainly advise differently.
Promotion of lifestyle changes targeting cardiac and other health problems is not mutually exclusive with targeting prostate cancer to reduce suffering caused by symptoms and to save the lives particularly of those who experience more aggressive forms of the cancer and/or who develop it at a younger age. One might debate the proportion of funding for various campaigns but really, the amount we are talking about for this prostate cancer campaign was relatively small.
Certainly, it’s important to provide accurate and balanced information about risk, diagnosis and treatment as these things stand at any present time, and criticisms regarding accuracy in the recent campaign may well be valid and worth addressing. However, it’s also true that with increased attention and investment will come increased research and knowledge including more reliable diagnostic tests.
589 deaths is a significant number, greater than both the male suicide toll and road toll. Of course it’s important to invest something towards reducing prostate cancer deaths as well as ameliorating suffering caused by symptoms.
Man X Norton I am an expert. I’m a General Practitioner with decades experience in screening and treating Prostate Cancer. What is known is that screening for Prostate Cancer hasn’t been shown to reduce mortality rate. What is also known is the treatment of Prostate Cancer causes morbidity and mortality.
Man X Norton if anybody is a
it would be you.
I haven’t claimed any personal expertise, but the information I have passed on comes from my wife, who is Head of Department of General Practice and Primary Health Care at Auckland University (ie: she teaches doctors this stuff). I read most of the academic literature on prostate screening in peer reviewed journals, and with current tests, screening will NOT save lives.
Fair enough, I’m no expert. But I made no mention of screening and as stated earlier, the topic leading to this discussion was a campaign to raise awareness. And as stated earlier, it cannot be true that seeking help and that all diagnosis and treatment of prostate cancer is worthless because I personally know two men who suffered from symptoms when they were young men and they sought help, were diagnosed and treated and they haven’t had symptoms since. There are other treated survivors on the Postie Ride Adventure.
So ‘nickcoop’, if someone comes to you describing strong symptoms of prostate cancer do you just tell them to go away, there’s nothing you can do?
If you look at my first comment (#2), I said:
There are a number of effective treatment options, and one of them may well save your life.
But screening all men, even if they don’t have symptoms, is a very bad idea. This is indeed the subject of this post; the article it links to begins:
Cancer sufferers (and people afraid of having cancer) are particularly vulnerable to snake-oil salesmen, and it is vitally important that any “raising awareness” be based on the best scientific data available.
The amount of funding available for health promotion (particularly that targeting men) is severely limited, and it is important that it be spent where it will do the most good.
Political campaigns based on emotion and misinformation are not a good way of influencing spending decisions, in my view. I think in this case, the Ministry of Health is NOT acting in the best interest of men with the advice it is giving.
Man X Norton, there are no symptoms that are exclusive to Prostate Cancer. (Br J Gen Pract. 2004 Aug;54(505):617-21.) Most men presenting with lower urinary tract symptoms (LUTS) have a benign disease. Unfortunately there has been so much scare mongering by groups with vested interests that many men I see with LUTS are convinced they have a Prostate Cancer that needs treatment. Most of what I see is Benign Prostatic Hyperplasia (BPH) which is amenable to medical treatment. So in answer to what I think is your question Man X Norton, if I see a patient with LUTS I investigate and treat them as appropriate. I do not tell them to go away as there is nothing I can do.
nickcoop: So if you usefully investigate symptoms to make a differential diagnosis, surely it’s a good idea that men suffering symptoms come to see you? And some of those men will have prostate cancer or some other disease, and some of those who can usefully be treated whether it be for prostate cancer or something else but not if they never came to have the symptoms checked out. If other medical practitioners are charlatans or simply don’t do a good job of investigating, diagnosing and sensibly recommending treatment options (including no treatment), well that’s not the fault of a public information campaign.
JohnPotter: You keep repeating the point that screening all men is a bad idea, even though I accepted that from the outset. Not sure why you see any argument there. My understanding of the campaign was that it was not a mass screening campaign (in fact it did not do or provide for any screening at all) but an awareness raising campaign. I have already stated that information should be accurate and that there may have been inaccuracies in the campaign in question. I’m not sure why you see any argument there. I have disagreed with those who have argued or implied that no prostate campaign of any kind is justified. There are several good reasons for prostate information campaigns including (i) helping people make decisions about whether to get possible symptoms or predispositions assessed, (ii) normalizing the topic and the idea of getting possible symptoms assessed, (iii) saving or improving the lives of people who otherwise may not have sought medical advice about symptoms, (iv) showing official and public attention to an exclusively male problem and thereby modelling caring attitudes about men (a rare thing indeed), (v) making at least some small gesture towards gender equality, and (vi) stimulating research and treatment progress.
And I have disagreed with the idea stated or implied by some that it’s not worth anyone seeking assessment or treatment for possible prostate cancer. Again, my two friends disprove that and they are enough to disprove that, but of course there are others too.
Man X Norton says:
There are definitely many health professionals who argue this position. Most of them stand to gain financially from what I can see. I accept that you aren’t promoting this.
“Awareness campaigns” which increase testing and unnecessary treatment likely have the same motivation. Manipulating people’s fear of cancer has long been an effective marketing tool.
This certainly sounds good in theory. But the evidence suggests that men will in fact be harmed if there is a significant increase in PSA testing. GPs are human, and susceptible to pressure from their patients.
This kind of political motivation has no legitimate place in the allocation of limited health resources, in my opinion.
JohnPotter: You are suggesting that our Ministry of Health engaged in a marketing campaign in order to spread fear and increase the wealth of cancer specialists? Seems a bit far-fetched.
You still have not addressed the reality that, for all the shortcomings in prostate cancer diagnosis and treatment, some men’s lives are saved or improved through it. Of the 600 or so deaths each year said to be caused by prostate cancer we don’t know how many may have survived had they sought earlier assessment and advice regarding intervention options, their risks and possible benefits. It is those men who may benefit from an awareness-raising campaign that should of course be based on the best science we have available. As I have repeatedly pointed out, if diagnosis and treatment of prostate cancer has any value then there will be value in raising awareness about this. And I have pointed out that diagnosis and treatment can be effective. If the Ministry of Health’s campaign included inaccurate information then that could usefully be challenged but I have seen little throughout this thread describing either any particular inaccuracies or suggestions for a better awareness campaign, only a generalized railing against any action regarding prostate cancer at all. The view that comes across here is that most old men get the cancer and nobody need care about them, the 600 or so old and younger men who die ‘of’ as opposed to ‘with’ the cancer don’t matter much compared with those who die of some other conditions, if you have symptoms that degrade the quality of your life just put up with it because diagnosis and treatment is a waste of time, and health funding should only go towards diseases other than prostate cancer. I don’t agree with any of those ideas.
While you have been keen to argue against some of the points I have made you have seemed reluctant to respond to others and certainly to concede anything. It’s weird that the debate on prostate cancer, an important male issue, has become so polarized and confused with a debate on mass screening, that now any efforts to diagnose, treat or raise awareness about it are seen as unacceptable.
Man X Norton asks:
I didn’t mean to imply this is a deliberate strategy by MOH, but I certainly think they are influenced by cancer specialists. Why would this be “far-fetched”?
I think they are also influenced by well-meaning male health activists who don’t understand the science.
All I am advocating is that any public health promotion and intervention should be evidence-based.
The current evidence suggests that lives will NOT be saved by increased “awareness” and diagnosis of prostate cancer. It also suggests that large numbers of men will be harmed by this approach. There are links to authoritative peer-reviewed research in previous comments.
I have already pointed out that you are misrepresenting the position on this, which I made clear in my first comment.
Men with symptoms should talk to their doctor.
My concern is that usually well-informed men with no symptoms like Downunder get regular PSA tests in the mistaken belief that they are looking after their health.
#31. Sorry John, but I have met a fair few men at my local Prostate Support Group who had no “symptoms” and had a PSA test included as part of the usual blood tests checking cholesterol etc, only to discover that their PSA readings were way above what they should be for their ages. And now after treatment or surgery, they are still ALIVE. Which is better than the alternative …..
Hi golfa, the evidence is that investigating and treating asymptomatic men with elevated PSA’s for Prostate Cancer doesn’t improve their life expectancy.
#33. What Doctor in his right mind would treat an asymptomatic man with an elevated PSA level without doing a biopsy to see if cancer is present ?
Let me put this as simply as I can. Men with Prostate Cancer don’t give a toss what “evidence” in ANY study says. Maybe that will dawn on you when you have it.
We go to the doctor and our PSA level is normal and we are happy campers.
If there was mass screening of men and your results said:
alcohol consumption – too high
exercise participation – too low
stress levels – too high
down time – too low
vegetable intake – too low
read meat intake – too high
Would you cope – you’d probably stop going to the doctor.
Hi golfa, if you have an elevated PSA why would you want to undergo a prostatic biopsy with all the risks involved if it isn’t going to improve your life expectancy?
The prostate debate rears its head in England in this BBC article: Prostate cancer tests miss severity in half of cases
And here again in the Telegraph: Men with prostate cancer ‘falsely’ told it is not aggressive
I guess the apparent confusion just says that more research is required. Good old funding fight between women’s and men’s medical issues, not forgetting the underfunding of mental health treatment and mental health research and we could do with more criminological research and perhaps more social research……
Waipukurau wasn’t built in a day, even if it was knocked down in a day?
The “apparent confusion” is caused by the misinformation that is promoted by people who should know better.
It is well established that PSA testing is NOT reliable for asymptomatic men.
As I noted in comment #2:
Yeah, we shouldn’t do anything to try to diagnose prostate cancer. Just let men have it and die without bothering us or costing anything. Mostly they’re past the age they would be paying so-called ‘child support’ anyway so who needs them?
My comment last night was partly in response to Murray, and partly in response to other comments that were so misleading that I decided to delete them.
Now that I have read the two articles that Downunder linked to, I see that they were referring to men who have actually been diagnosed with Prostate cancer, and the lack of reliable treatment options.
This is a different issue from that of screening, and probably deserved a post of it’s own. I note in ‘related stories’ on the BBC site there is an article titled “Prostate screening has no benefit“, which reviews the evidence that the harms outweigh the benefits.
I don’t see anyone suggesting that “we shouldn’t do anything to try to diagnose prostate cancer”.
My understanding is that far from being past the age of paying child support, these extremely aggressive forms are much more likely in younger men.
I think the real issue is that there needs to be more research into testing for this disease, not that we need political pressure to change current treatment protocols. This guy says it pretty clearly:
Thanks John. I am genuinely interested though in what exactly you would suggest is done towards assessing and diagnosing prostate cancer, given that the current diagnostic tests are so unreliable.
Diagnosing prostate cancer and deciding on the most appropriate treatment is something that will be different on a case-by-case basis, so I don’t think there is any protocol that can be promoted for everyone.
Men need to discuss prostate issues with their general practitioner, taking into account all the information they are able to get, understanding the limitations of any testing they undergo, and assessing the level of risk that comes with any particular intervention.
The decisions they make may be quite different depending on factors like family history, age, general health, personal level of fear, financial situation, how much they enjoy fucking, etc., etc.
If there is a place for political action I think it should be aimed at demanding research money for developing more accurate tests.
I don’t know if any studies of this kind are currently underway in NZ.
Surviving prostate cancer: a prostate surgeon’s story The Observer
Drug Company Makes it a Battle of the Sexes
New Prostate Drug
What’s this all about?