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Fresh row over prostate screening

BMJ 2003; 326 doi: (Published 15 March 2003) Cite this as: BMJ 2003;326:605
  1. Simon Chapman, professor of public health (simonc{at}
  1. University of Sydney, Australia

    Professor's admission challenges Australia's reverence for medical tests

    In 2001 Michael Wilkes and Gavin Yamey, then editors of the Western Journal of Medicine, argued in the San Francisco Chronicle that there was no good evidence to screen healthy men for prostate cancer. Their article provoked an enormous backlash and they were subject to some particularly vicious lobbying and character assassination. They were said to be promoting “geriatricide,” and efforts were made to have them sacked (BMJ 2002;324:431).

    In Australia in recent weeks, it has been the turn of Professor Alan Coates, chief executive of the Cancer Council Australia, the nation's peak cancer control policy body, to be on the receiving end. Professor Coates had featured in a lengthy report in the Australian Financial Review in February, where he declared that he would not choose to have a prostate specific antigen (PSA) test. He said, “The test may find things that didn't need to be found or it may find things when it is too late to fix them. The supposition is that there is a group in between where it finds something early enough to make a real difference, but there is no proof that such a window of opportunity exists.”

    The Sydney Morning Herald called Professor Coates “the apostate professor” whose actions will have confused thousands of men. A federal politician described his statement as “public policy vandalism.” He added that it “must be exposed for what it is—contempt for men and their families,” which had “torpedoed” a planned public awareness campaign by causing a sponsor to withdraw. Several prominent urologists and advocates for widespread use of the test called for Professor Coates's resignation. Prostate cancer survivors who had been tested expressed their dismay.

    Australian urologists are markedly divided on prostate testing. Neither the Urological Society of Australia nor the Australian Prostate Cancer Collaboration support population screening, joining all Australian cancer councils, the US Preventive Services Task Force, and the UK Health Care Evaluation Unit in this position.

    This episode has raised challenging communication questions for people in cancer control asked by a journalist to disclose their own actions. With widespread reservations about the wisdom of PSA testing, it is likely that many highly informed cancer officials like Professor Coates would elect not to be tested. Journalists understandably feel this is newsworthy.

    Professor Coates's critics have called him irresponsible for declaring his personal decision. But as lying is indefensible, and dodging such a question as inappropriately personal would effectively mean “no,” Coates could hardly have answered differently.

    The torrent of abuse and ill informed accusations that were unleashed say much about the Australian community's unconditional reverence for medical tests and the fertile ground this creates for those promoting them. Test advocates have skilfully matched the availability of the PSA test with deeply sacrosanct values about the right to know and being “fully informed.” Those taking the considered view that it is often wiser to leave well alone are forced to argue for the virtues of remaining ignorant.

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