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>From spikedonline
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Article30 March 2001
Why 'awareness' is bad for your health
by Dr Michael Fitzpatrick
'"You know who's dead? Bert and Utty", Mendy said. "Prostate cancer. Went to the
spine. Spread. Ate 'em up. Both of them. Thank God I get the test. You get the test?"
"What test?" the other fellow asked. "Shit, you don't get the test?" "Skip", said
Mendy,
pulling me away from Ira, "Meisner doesn't get the test".'
(Philip Roth, American Pastoral, 1998, p56)
This exchange was recorded by Philip Roth's fictional alter ego Nathan Zuckerman at
the
forty-fifth annual reunion of his New Jersey high-school class of 1950, an event at
which tales of disease and death come high on the agenda for discussion. Mendy
has just told Zuckerman ('Skip') that he gets his PSA (Prostate Specific Antigen) test
every six months, while Zuckerman, who is impotent as a result of surgery for
prostate cancer, tells Mendy that he still gets the test 'every year'.
The week ending 30 March 2001 was Prostate Cancer Awareness Week in the UK,
and UK
health secretary Alan Milburn announced that British men are to be offered screening
tests for the disease for the first time. Though the government has stopped short of
introducing the full national screening programme demanded by some men's health
campaigners, the PSA test is to be made available on the NHS through GPs to any
man who asks for it. Soon men in Britain will be able to compare PSA levels in the
pub and share prostate awareness via the internet with their American brothers.
The men's health movement has adopted a ribbon - purple (Why purple? Don't even
go
there!) - and has even held its first demonstration. Last September the Coalition for
Prostate Cancer marshalled 'doctors and men with prostate cancer' for a march on
Downing Street to demand more government funding to fight the disease. The tone
was set by Major Ronald Ferguson, who is distinguished not only for fathering Fergie,
but also for having 'battled' against prostate cancer. 'Something must be done
urgently' declared the major.
The UK Observer dutifully kicked off the week of awareness with the personal
testimony of
another celebrity sufferer - Bruce Kent (1). Once a prominent figure on the CND
marches of the 1980s, Kent now seeks to challenge the 'ignorance and misplaced
shame' about prostate cancer. His recent prostate removal appears to have pushed
him back into the pulpit mode he knew in a still earlier life as a Catholic priest:
'Some
of the battles of the day become a little less important when one has heard a
knocking on the door.'
It seems that men's health campaigners have assimilated much of the style and the
rhetoric
of the old protest movements, together with their erstwhile leaders. But rather than
trying to change the world, their object is to raise men's awareness of their
impending mortality and to encourage them to concentrate their energies on trying to
preserve their crumbling bodies. Whereas once the radical project of
'consciousness-raising' sought to advance diverse forms of social liberation, 'raising
awareness' of cancer seeks to reconcile individuals to the inevitability of suffering
and death.
The campaign for greater public awareness of prostate cancer reflects a fatalistic
mood in
contemporary society. It is also likely to be damaging both to public health and to the
health service. This is because it is based on two myths: that prostate cancer can be
readily detected by screening tests and that, if detected early, it can be effectively
treated by currently available methods.
The case against population screening for prostate cancer is scarcely controversial:
it was
made by the UK National Screening Committee to the government in March 1997
and accepted (2). The reasons for this were: 'The PSA test had a limited accuracy
and could lead to a positive result for those without the disease. Follow-up
procedures with side-effects of impotency and incontinence could cause
unnecessary harm to healthy individuals.
'There was no medical consensus on how to treat the disease.'
The PSA test yields both false positive and false negative results. Depending on the
cut-off
level used, up to two thirds of men who have raised PSA levels do not have prostate
cancer. On the other hand, some men who have prostate cancer do not have raised
PSA levels. However, once somebody has had a test yielding a high result, this leads
inexorably to more invasive investigations, such as a transrectal needle biopsy,
which is every bit as uncomfortable as it sounds, and also carries risks of
haemorrhage and infection. At present only 30 to 40 percent of men having a biopsy
for raised PSA are found to be positive for cancer, a proportion that is likely to
decline as more men demand PSA tests.
A positive diagnosis of prostate cancer leads to further problems. There is a wide
variation in
the rate at which this poorly understood tumour develops. In some men, it grows
rapidly, spreads to the bones and causes death within a few years. More commonly,
it grows slowly and never causes wider problems - most patients die of other causes.
It is not at present possible to differentiate between these two extremes at an early
stage, making it difficult to decide on the best form of treatment.
Various treatments are available - including surgery, radiotherapy, hormone therapy -
but the
evidence for the superiority of any particular treatment is poor. All carry significant
risks, notably of impotence and incontinence. Radical surgery ('prostatectomy') is
more popular in the USA, where PSA testing is more widespread and early diagnosis
more common, but the balance of benefits and dangers remains unclear (the rate of
death during surgery in the UK is estimated at 0.4 to 0.6 percent).
Why then has the government changed its line on screening for prostate cancer? No
doubt
political considerations play a part. Though the decision not to implement a national
screening programme was taken by the previous Conservative government, William
Hague has made a 'prostate pledge', proposing screening for all men aged between
50 and 70 (3). With an election pending, Tony Blair and Alan Milburn are keen to be
seen to putting issues of health - and cancer has a particular appeal - high on the
agenda.
However, Milburn has stopped short of introducing a nationwide programme. Instead
he
proposes an 'Informed Choice' scheme, under which GPs will provide men with an
'information pack' explaining the options. Once men have been made fully aware of
how useless the PSA test is, of the risks of further intervention and the lack of
evidence for the benefit of early treatment, then they can make up their own minds
about whether to go ahead with the test.
This approach follows the model of post-BSE transparency and openness, in which
the
government abdicates responsibility for deciding on sensitive areas of policy and
shifts the burden on to the public. The political calculation appears to be that an
image of concern about cancer and sensitivity to pressure groups is more important
than the practical consequences of the policy.
Yet the backdoor introduction of prostate cancer screening will have serious adverse
consequences. The increasing scale of the promotion of prostate awareness over
recent months, which has been eagerly taken up by the tabloid as well as the
broadsheet press, has already produced an increase in requests for PSA tests in my
surgery. Many of these have been from men in their twenties or thirties, whose risk of
prostate cancer is negligible (95 percent of cases occur in men over 65). Some, who
have gone to the trouble of taking time off work and booking an appointment, are not
to be deterred from having the test. We have already begun to see the anxious faces
of men with equivocally raised PSA levels, seeking referral for specialist assessment.
Furthermore, this wave of demand comes at a time when local urological services
are already under great strain, with long waiting lists and unsatisfactory delays. When
clinics are swamped with the worried well, the really ill will suffer, a trend that is
already apparent in many areas of the health service.
The inevitable result of greater public awareness of prostate cancer will be that large
numbers of men will be subjected to investigations (and even treatment) that will be
of no benefit to them, while causing considerable adverse effects. Furthermore, this
enhanced awareness will not benefit men with prostate cancer: indeed it will divert
resources both from their treatment and from the research necessary to discover
more effective screening tests and treatments.
Dr Michael Fitzpatrick is the author of The Tyranny of Health: doctors and the
regulation of lifestyle, Routledge, 2000. Buy this book from Amazon (UK) or Amazon
(USA)
(1) Observer, 25 March 2001
(2) See the Department of Health website
(3) BBC News Online, 11 November 1999
Reprinted from : http://www.spiked-online.com/Articles/00000000554D.htm
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