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Prostate screening: worse than useless if multi-needle biopsy spreads cancer
The BMJ publishes a clear guideline based on an excellent systematic review confirming yet again a population screening strategy that does not ‘work’: asymptomatic men are harmed by routine PSA testing.(1) For every 1000 men screened vs not screened there is no reduction in all-cause deaths, and a great many men damaged by ‘life-changing’ labels, invasive investigations, treatments and complications. Yet many men are offered ‘routine’ PSA checks and think them a good idea,(2) few realize they are not.(3) Privately, morose doctors comment that no one’s more grateful than incontinent, impotent men who believe their lives ‘were saved by screening’. Even the test’s founder decries it.(4)
Meanwhile money spent on screening and its aftermath is diverted away from effective treatments for the sick. Maybe evidence has no impact because men aren’t shown the excellent available decision aids,(1,5) or they aren’t warned about the uncertain safety of multi-needle prostate biopsy which has the potential to cause needle track spread and local extension?(6,7) Failing to look for, and correctly stage, extra-capsular tumour preoperatively might partly explain the failure of screening strategies to improve survival. The general public deserves new, explanatory narratives. It’s possible to live healthily and long with small specks of dormant cancers. It’s not a good idea to search out and biopsy indolent lesions with multiple needles, just as it’s dangerous to poke sleeping dogs with sticks.
Competing interests:
SB declares no interests (see www.whopaysthisdoctor/58), GDS participated in the ProTecT trial.(8) Unusually, post positive biopsy, he underwent ultrasound examination which showed unexpected extra-capsular tumour spread, confirmed and demonstrated in greater detail by MRI scan.
27 September 2018
Susan Bewley
Professor (emeritus) of Obstetrics and Women's Health
G. David Stainsby, FRCS, Retired Consultant Orthopaedic Surgeon
King's College London
Department of Women's and Children's Health, c/o 10th floor St Thomas' Hospital, Westminster Bridge Road, London SE1 7NH
Rapid Response:
Prostate screening: worse than useless if multi-needle biopsy spreads cancer
The BMJ publishes a clear guideline based on an excellent systematic review confirming yet again a population screening strategy that does not ‘work’: asymptomatic men are harmed by routine PSA testing.(1) For every 1000 men screened vs not screened there is no reduction in all-cause deaths, and a great many men damaged by ‘life-changing’ labels, invasive investigations, treatments and complications. Yet many men are offered ‘routine’ PSA checks and think them a good idea,(2) few realize they are not.(3) Privately, morose doctors comment that no one’s more grateful than incontinent, impotent men who believe their lives ‘were saved by screening’. Even the test’s founder decries it.(4)
Meanwhile money spent on screening and its aftermath is diverted away from effective treatments for the sick. Maybe evidence has no impact because men aren’t shown the excellent available decision aids,(1,5) or they aren’t warned about the uncertain safety of multi-needle prostate biopsy which has the potential to cause needle track spread and local extension?(6,7) Failing to look for, and correctly stage, extra-capsular tumour preoperatively might partly explain the failure of screening strategies to improve survival. The general public deserves new, explanatory narratives. It’s possible to live healthily and long with small specks of dormant cancers. It’s not a good idea to search out and biopsy indolent lesions with multiple needles, just as it’s dangerous to poke sleeping dogs with sticks.
References
1. Tikkinen KAO, Dahm P, Lytvyn L, Heen AF, Vernooij RWM, Siemieniuk RAC, Wheeler R, Vaughan B, Fobuzi AC, Blanker MH, Junod N, Sommer J, Stirnemann J, Yoshimura M, Auer R, MacDonald H, Guyatt G, Vandvik PO, Agoritsas T. Prostate cancer screening with prostate-specific antigen (PSA) test: a clinical practice guideline. BMJ 2018;362:k3581 BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3581 (Published 05 September 2018)
2. Fry S. Stephen Fry announces he has prostate cancer. https://www.youtube.com/watch?v=9yDNAc8YS9c&feature=youtu.be (last accessed 27 Sept 2018)
3. Monbiot G. I have prostate cancer. But I am happy. https://www.theguardian.com/commentisfree/2018/mar/13/prostate-cancer-ha... (last accessed 27 Sept 2018)
4. Albin RJ. The Great Prostate Mistake. https://www.nytimes.com/2010/03/10/opinion/10Ablin.html?pa (last accessed 27 Sept 2018)
5. Harding Centre for Risk Literacy. Early detection of prostate cancer with PSA testing and a digital rectal exam. https://www.harding-center.mpg.de/en/fact-boxes/early-detection-of-cance... (last accessed 27 Sept 2018)
6. Stainsby GD. 10-Year Outcomes in Localised Prostate Cancer. Letter to Editor. N Engl J Med 2017; 376: 178-181. January 12: 2017. https://www.nejm.org/doi/full/10.1056/NEJMc1614342
7. Stainsby GD, Bewley S. Patients’ roles and rights in research https://www.bmj.com/content/362/bmj.k3193/rr-10
8. ProTecT study. Prostate testing for cancer and Treatment. HTA No 96/20/99. Principal investigators: FC Hamdy, JL Donovan, DE Neal. Coordinator: JA Lane. https://www.nejm.org/doi/full/10.1056/NEJMoa1606220
Competing interests: SB declares no interests (see www.whopaysthisdoctor/58), GDS participated in the ProTecT trial.(8) Unusually, post positive biopsy, he underwent ultrasound examination which showed unexpected extra-capsular tumour spread, confirmed and demonstrated in greater detail by MRI scan.