The Great Prostate Cover up
To mark the start of Prostate Awareness month in November, Rory Hafford talks about the Great Prostate Cover Up.
A number of years ago I made a TV documentary for RTE on beloved poet and writer John B Keane. Keane had been diagnosed with prostate cancer and he wanted to speak to the nation’s men-folk on how best to tackle the problem.
While the cameras were rolling, John B was his usually inimitable self — funny, informative, hugely entertaining. But, when the cameras stopped rolling, that’s when his real feelings emerged.
Do me a favour
The man was devastated with the diagnosis and, more importantly, the prognosis. He knew he hadn’t long to live. He pulled me away into one of the snugs of his little Listowel pub and asked me to do him a favour: ‘When I’m gone,’ he said, ‘get them (the health watchdogs) to answer just one question for me… why couldn’t they have spotted this dreadful disease sooner, at a time when they could have done something about it?’
I promised him I would. We packed the cameras into the van and Listowel receded behind us as we headed back to Dublin. Not long after, John B passed away. I have kept my promise to the man and have written a book called Man Trap. It’s an investigation into the whole area of prostate management in Ireland and a study into the viability of introducing a screening programme to stop the hundreds of deaths that take place in this country every single year. It proved to be a very interesting exercise…
Just recently Ireland got its very own cervical screening programme, which is fantastic. The move follows hot on the heels of the very successful Breast Screening programme.
Both initiatives were launched with much fanfare and the message was trumpeted that ‘screening saves lives’. Two screening initiatives to tackle cancers that are female-specific. Excellent! Now, what about the men?
Eh, well, you see, it’s not that simple with men, we are informed. ‘Best Practice’ would suggest that screening for activity in the prostate does not necessarily translate to lives saved. This is just one of the usual arguments trotted out.
There are a few more. Let’s look at them:
* The Prostate Specific Antigen (PSA) test is not specific enough. Sure it can pick up malignancies, but it can also just point to a simple infection;
* Digital Rectal Exam (DRE). Men don’t like it!
* If we did introduce a screening programme to Ireland, the paucity of urologists would be a problem;
* You could create an army of ‘worried well’;
* Population-based screening has never been shown to actually save lives. There are a number of major studies ongoing, but we just don’t have the results from these yet.
Now, remember, this year alone 600 Irish men died because of prostate cancer; not ‘with it’, but ‘ because of it’. It could be argued that these men would still be alive today if we had a screening programme. And, get this: next year another 600 men will die.
And what do the authorities do about it? Nothing. Okay, there are various awareness programmes launched now and then, usually sponsored by the pharmaceutical industry, designed to encourage men to get along to their doctor to find out what’s going on ‘under the bonnet’.
Awareness is good; I’m not knocking it. However, most men (and a myriad of studies back this up) will not get themselves along to their doctor for a check-out. In fact, most men would rather chew their arm off first. So, we need something a little bit more effective.
Screening programme
I talked to a number of GPs while researching the book and asked them if they would, as a matter of course, run a PSA test on a man who presented in the ‘at risk’ group. I was told ‘No!’ It shouldn’t be up to GPs to take the initiative on this, I was told. There should be a dedicated screening programme in place, if we want to do it properly.
Now, let’s take a closer look at the arguments outlined above:
The PSA test (which was not designed as a screening tool in the first place) is not specific enough, we are told. Okay, fair enough. But, you do know that there are other more sensitive PSA tests that could do the job.
For instance, there is a complex test, or cPSA that is a lot more targeted in its approach. There is also a PSA velocity test (based on changes in levels over time); Age-adjusted PSA; Free versus Attached PSA; Protein Patters in relation to elevated PSA. There are many options associated with the PSA approach which haven’t been fully explored yet. The question is… why not?
The argument that we would create an army of worried well doesn’t hold up in my book. Sure, any screening programme runs this risk, yet we have screening programmes for all manner of ailments. I’ll tell you this, I’d rather be worried and well than blissfully ignorant and not so well. Wouldn’t you?
We are told that the jury is out on population-based screening programmes and that we are still waiting for a few major studies to be completed before we have the full picture. This is also not true. There are many ‘major’ studies completed at this stage and all of them point to the fact that population-based screening saves lives. Here’s just a few: the Quebec study, which was headed up by Dr Bernard Candas and ran for a full 11 years (it doesn’t get more ‘major’ than this). His conclusion: ‘Metastatic prostate cancer should be avoidable through screening. We found a strongly positive and highly significant relationship between the rate of PSA testing and a reduction in prostate cancer deaths’.
The 2004 study in Tehran, which ran for nine years and looked at close to 4,000 men concluded with the comment: “PSA-based screening (with low cut-off values) increases the detection rate of clinically significant, organ-confined and potentially curable prostate cancer.” The recently concluded Swedish study carried out in Sahlgrenska University Hospital, which looked at 10,000 men found that ‘PSA screening detected early-stage low-grade prostate cancer’.
Drawbacks
Finally, the issue of DRE. Even if you could get a man to agree to this examination, it still has its drawbacks. You can only feel for clinically significant changes on the bottom and the sides of the gland. There could be more activity on the bit that you can’t reach.
But, again, there is an alternative and it comes in the form of a revolutionary 3-D imaging technique that is being championed by a clinic called the Irish Centre of Integrated Medicine in Naas and does away with the invasive test. It could be argued that this clinic is set up and ready to go as a national prostate screening centre! Prof. John Fitzpatrick has long asked for the issue of screening to be re-examined in Ireland. He talked to me for the book: ‘On a national prostate screening programme for Ireland my heart says yes. I do believe that we need to diagnose this disease early to give ourselves the best chance of treating it. I know that screening is available in many areas of the States, for instance. But I also believe that we need an Irish study to give us Irish evidence so that we can tailor a programme specifically for this country,’ says Prof. Fitzpatrick.
Simple logic
Let’s conclude with my simple logic: if you look for something, surely you have a better chance of finding it? And, if you find it, surely you have a better chance of treating it effectively? Prostate cancer is no different from any other cancer in that regard. But we’re not looking for it.
For the sake of John B Keane; for the sake of the thousands of Irish men who will be diagnosed with advanced prostate cancer this year; for the sake of future generations…maybe we should be looking for it.
- Man Trap – Dealing With Prostate Cancer, by Rory Hafford, is published by Liberties Press and will be launched in October of this year.
Posted in The Irish Medical Times on 17 September 2008
Tags: Detect Cancer, Prostate
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