This week's Journal of the National Cancer Institute includes a new analysis by Gilbert Welch and Peter Albertsen showing how much overdiagnosis and overtreatment have been the result of 20 years of more aggressive prostate cancer screening.
American Cancer Society chief medical officer Dr. Otis Brawley wrote an accompanying editorial. Excerpts:
In this issue of the Journal, Welch and Albertsen presented information that every man considering prostate cancer screening and treatment should know and understand. Prostate cancer screening has resulted in substantial overdiagnosis and in unnecessary treatment. It may have saved relatively few lives. Results from this article and recent results from prostate cancer screening and prevention trials demand reflection about what we as a society have done and are doing. Lessons to be learned have ethical and economic implications and involve our lack of respect for the scientific process and scientific evidence.
As I sat down to write this editorial, I heard a radio commercial that brings perspective to the issue. A local celebrity was promoting prostate cancer awareness. He said, "Prostate cancer is 100% curable when caught early." He encouraged all men to get screened and announced that a van was touring the area offering screening in supermarket parking lots. This was a community service project sponsored by the radio station, the supermarket chain, and a radiation oncology practice.
A commercial like this plays to our fears and prejudices. ...
Many screening advocates (both physician and lay) have had difficulty accepting that some cancers are not going to progress and cause symptoms or death within the lifetime of the patient. The distinguished urologist Willet Whitmore recognized overdiagnosis as a problem in his famous quote, "The quandary in prostate cancer: Is cure necessary in those for whom it is possible, and is cure possible in those for whom it is necessary?"
Brawley also includes some very important lessons - for medicine and for health care consumers:
Have respect for science and the scientific process. Understand and address the truly important questions.
In the past we have truly not appreciated the need for scientific evidence. In the future, will we accept scientific evidence?
Know what is known, know what is not known, and know what is believed. Label them accordingly.
I come from and have been supported by an African American community, where many are suspicious of physician motives and are convinced that doctors and those in medicine will take advantage of them and not tell them the truth. Distrust is actually a major reason for many disparities in health faced by black Americans . A closed-minded medical culture is a part of the problem. The well-meaning uninformed layman with a sound bite is also a part of the problem. Both can cause serious harm.
...The benefits of prostate cancer screening are still open to question. This means that informed or shared decision making should be done using the data now available before screening is performed. Some of the confusion of prostate cancer screening can be avoided if we all clearly label what we know, as what we know; what we do not know, as what we do not know; and what we believe, as what we believe. Of course, one must not confuse what is believed with what is known to do this.
Recently, a reader of this blog wrote:
With all the rhetoric from the U.S. Preventive Services Task Force (USPSTF) and their ilk, I still fail to see how PSA testing can in ANY WAY be harmful.
Rhetoric? Since when is evidence rhetoric?
"Their ilk?" Their ilk includes those, like Dr. Brawley, who responsibly and rationally assess the evidence.
Brawley said the Welch/Albertsen study presents information "that every man considering prostate cancer screening and treatment should know and understand." They should read his editorial while they're at it.