A Transatlantic screening debate

Much as US culture eventually wings its way over to the UK, and extends a huge influence over everything from gastronomy (a personal thank you for cheeseburgers and fries) to advertising and television, there are some areas on which we differ.

The approach to the PSA test, still the cornerstone of prostate cancer diagnosis across the globe, for want of a more reliable test, was until recently one of these points of difference. The USA has traditionally used the test as the basis of a screening programme.

The UK, taking a more cautious approach in the face of evidence of the risks of over-treatment as a result of screening, has encouraged men to make a choice through discussion with their GP about whether the test is right for them.

Now, the US is changing tack, which has sparked polarised debate in the US. The USPSTF* has revised its position even though the latest European trial results have strengthened the argument for screening by showing that its impact on reducing deaths from the disease may be higher than originally thought. The powerful pro-screening lobby, encompassing a broad range of prominent politicians and clinicians, is now occupying defensive territory – and making a lot of noise about the Task Force’s decision.

Interestingly, it is a position which isn’t binding. Patients and clinicians are asking, very often through the US media, ‘where do we go from here?’. Some doctors are adamant they will continue to screen their patients, with others less certain how to proceed. Barack Obama’s Health Secretary, Kathleen Sebelius, prompted by the anger generated by the USPSTF’s recommendation, has even gone as far as to put out a statement distancing the US Government from the Task Force to underline the fact that the body ‘does not set health policy’. This resulting furore shows how difficult it is to have this debate in the US public arena, given the very strong emotions involved. Emotive stories of people who believe they have benefitted from screening, are very powerful, and cloud even research-based statistics.

From a UK perspective, we can only agree with the Task Force’s decision, mirroring as it does our position and given the clear drawbacks of population-wide screening. Yet the unambiguous line here, even if it is controversial in some quarters, has its drawbacks. Debate around the test is at best sporadic, rearing its head with new research or a celebrity diagnosis. The interim silence can read as a quiet acceptance of the status quo. Men being expected to make a decision themselves around a flawed test, which could have far-reaching consequences for their life and health, can hardly be desirable, especially when we know some GPs have a bias. At least the divergent view points in the US, and the prominence of the debate, is showing that men deserve better. The volume is good. Maybe the discourse needs to be different – should it not be around research into a new generation test. One, which does not run the risk of ending a man’s sex life and causing incontinence unnecessarily. This is where our own research strategy is leading.

I am using this American-themed post to introduce a link to Dan Zenka’s blog. It chronicles not only his reaction to emerging prostate cancer-related issues, from the perspective of his role as Senior Vice President of the Prostate Cancer Foundation, but also his own battle with the disease. We met recently at a conference hosted by our partner Movember in ‘The States’, looking at how we can pool resource and expertise to channel resource effectively into global research priorities. Linking our blogs mirrors this intention to close boundaries. It is a small way of sparking debate and dialogue from a more universal perspective. That is exactly what we need to tackle this disease, a concerted, universal approach to make sure men with prostate cancer get what they need. A new test is the best starting point I can think of.

*US Preventive Services Task Force – an independent group of experts that make recommendations about services such as screening, counselling and preventive medications, in the USA.

3 thoughts on “A Transatlantic screening debate

  1. Thank you, Owen. Looking forward to one day soon moving beyond the PSA debate with a new test and to more cross-pond collaboration so we can overtreat less and cure more.

    Best regrads,
    Dan Zenka

  2. Message from Dave Beesley, Chariman of Oxford Prostate Cancer Support Group

    Hi Owen and Dan
    I like many others both agree and disagree but in my case after a simple PSA test and no symptoms it was proved I was Gleason Scale 7 and spread. So until that better test comes available we have no choice.
    I am extremely lucky to have had the PSA test and now my Prostate Cancer in undetectable.
    Surly we all have to continue to spread the awareness and it is up to each and every Man to decide for themselves if they want to be Tested.
    Dave Beesley Chairman of the Oxfordshire Prostate Cancer Support Support Group.

  3. Owen,
    I am glad that you have added exposure to the debate over PSA testing. Everything that can be done to highlight the equivocal and muddled situation should be a contribution to pressure for more honesty and determination in policy, the hypocrisy of which bestows a right on men yet denies them knowledge of that right by silence about it. It is staggering. But I must therefore challenge you over your claim that “The UK… has encouraged men to make a choice through discussion with their GP…”. No such encouragement exists in any consistent and active form, as the page referenced in your statement makes clear. If women were subject to the same selective and socially regressive effects in breast cancer diagnosis there would be an outcry. We men have been passive for too long, paralysed by horror of the Two-I's of impotence and incontinence. The NHS must be kept under constant pressure to implement an open, fully publicised and fair policy over “choice”.

    Would that I had had the chance of “overtreatment” rather than the certainty of early death through GP neglect when a test should have been offered. The PSA test is all we have; it has been shown to save lives. Pressure breeds action, lack of pressure licences complacency, and your statement adds to the latter. My support to the Charity, modest though it may be, is not intended for that purpose.

    Bob Melling

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