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Prostate cancer (again)

I've posted here previously about the pros and cons of testing for prostate cancer. This week's BMJ has an article on the subject (Wilt TJ, Thompson IM, Clinically localised prostate cancer. BMJ 2006:333;1102-6). The key points from this article are the same as those I've made previously. There was a paper giving similar conclusions in JAMA (Walter LC et al, PSA screening among elderly men with limited life expectancy. JAMA. 2006;296:2336-2342.)

Early detection of prostate cancer and treatment sound like a good idea but are difficult to provide in practice. Digital examination of the prostate and prostate specific antigen (the commonly used blood test, PSA) can both have false positive and false negative results. Many cancers would never cause problems in the lifetime of the patient.

Many older men have prostate symptoms such as frequency, hesitancy, night time urination, and slow stream, but these do not increase the risk of cancer although they do increase PSA levels.

If tests are done they are quite likely to lead to a prostate biopsy, which can cause bleeding, pain, and urinary infection.

There is also uncertainty about treatment. The available treatments (surgery, radiation, hormonal manipulation) may not work and have possible serious side effects.

The authors' conclusion is that doctors should not advise patients either for or against prostate cancer tests but should discuss the advantages and disadvantages. This is for men who are aged at least 50 and can expect to live for at least 10-15 years. Older men, who have lower life expectancy, are unlikely to benefit from routine testing.

A balanced discussion of the pros and cons of testing can be found here.


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John Floyd, MD on :

At least in the UK there is some effort to do what is best for the patient with prostate cancer, or at least at risk for it.
In the U.S. medicine has become so much of a business, that choices made for the patient may be based on other than the best science. For example, urology groups are now actually installing radiation therapy centers (http://www.nytimes.com/2006/12/01/business/01beam.html?ei=5087%0A&em=&en=c26f0f93b9015360&ex=1165208400&pagewanted=all) which have the potential for huge profits. . . as long as the urologist sends enough of his/her patients to their own center for external beam radiation, which is much more profitable than either surgery or radiation seed implantation (and of course far more profitable than doing nothing!
This is typical in the U.S. where cardiologists are buying nuclear cameras and CT scanners and oncologists are installing PET/CT scanners in their offices; all to increase the income of their practices. The US congress and the US insurance companies seem powerless to do anything about this abuse. Mainly, they just ratchet down reimburment for the procedures, hoping to drive these physicians out of business, but at the same time threatening the viability of therapy and imaging departments at the non-profit hospitals (who end up doing all the uninsured or poorly-insured patients).
For this, and other reasons, the U.S. healthcare system is headed for a cataclysmic event as the price of healthcare for the government and the private insurers approaches unaforadable heights. The national health system in the UK is not perfect, at least as I experienced it in the late 1970's, but universal care is a worthy goal for all societies.

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