One of our favourite sports is commenting on the frequent updated guidelines on prostate cancer testing. Currently there are SEVEN approved sets of guidelines – each of which differs from the others on who and how to test men without symptoms to see if they have cancer (screening).
Today, there is an eighth.
To be fair, the new guidelines are in draft form only, they aim to bring consensus to the process and they are looking at the evidence as carefully as one can.
The most interesting early discussion point is that digital rectal examination (DRE – the finger up the backside) is no longer recommended. This comes as a surprise to those of us who were taught that DRE is free, simple, side effect free and useful. But the best research study suggests that it only picks up a very, very small number of additional cancers and runs the risk on increasing the false positive rate (suggesting men have cancer and need biopsies when in fact there is nothing wrong).
The jury is still out on this and the guidelines are only in draft stage. But at least you can have some expert advice to back you up when you are arguing with your doctor about the merits of DRE!
See http://wiki.cancer.org.au/australia/Guidelines:PSA_Testing/Role_of_digital_rectal_examination for more details.
A recent study in the prestigious British Medical Journal raised the question – should there be an acceptable level of mistakes that doctors can make?
Counter-intuitively, striving less hard to always be right may be safer for the patients in the long run. Every test and every treatment has a cost – and not just financially. Tests are unpleasant and time consuming, medications have side effects and surgery often painful and debilitating.
Yet often all these tests and treatments are for no purpose other than “to be sure”. If we accepted that sometimes we will miss conditions in the early stages, it may be possible to significantly decrease the number of tests and treatments we perform.
To be sure that may result in some things being missed. But it will also significantly decrease the number of problems that we cause.
Getting the balance right is the great challenge of modern medicine.
A fascinating article on the website The Conversation discusses whether we should abandon the word “cancer”. Why? Because so many cancers these days are so minor that they won’t ever cause any harm to the patient. But the very act of using the word cancer can frighten people well out of proportion to the danger they face.
This is particularly so for cancers which are found by screening tests. The theory is that finding a cancer in the early stages improves the odds of survival. The best known examples are prostate and breast cancer.
Yet interestingly, after 30 years of screening for breast cancer in the USA, the number of minor cancers detected has doubled … but the number of advanced cancers detected has dropped by less than 10%. In other words, lots of new cancers are being found, but they were unlikely to ever cause any problems even if not discovered. The same applies – perhaps more so – to prostate cancer.
These extra “cancers” also make the figures for treatment look much better. If you “treat” all cancers – including those that aren’t nasty – your survival figures will dramatically improve.
The discussion around renaming these early or minor cancers is part of a movement in medicine against over-diagnosis and over-treatment. Doctors and patients both have a role to play – doctors need to think more clearly about the implications of conditions, and patients need to understand that medicine is not perfect, that we are always learning and re-evaluating our knowledge; and that doing more can be worse than doing less.
Once upon a time doctors were encouraged to use their own judgement. Now we are encouraged to follow guidelines (though they are really just somebody else’s judgement about what is best for the population as a whole, not specifically targeted at the patient sitting in front of us, and certainly not as immutable as the 10 Commandments).
So it’s pretty confusing for patients – and highly confusing for doctors – to realise that there are currently – count them – seven sets of “official” guidelines in Australia for what is best practice in testing for prostate cancer. And they all differ. It would be nice if the learned Colleges of Pathology, Surgery, General Practice, the NHMRC, Medicare etc could agree.
Let’s add one more to the list. A new study from Sweden (www.bmj.com/content/346/bmj.f2023) suggests that men should only be tested three times in their lives – around the ages of 45, early 50s and age 60. If each of those tests is normal, their lifetime risk of prostate cancer is very low. If any of the tests is above average, then testing more often is called for.
The theory (and evidence) is reasonably good. Whether this recommendation will be adopted by all the experts remains to be seen. And sometime in the next week or two, you can expect a new set of guidelines to be released…..