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Screening for prostate cancer

Some of the jewels in the NHS R&D Directorate crown were apparent very early in this great experiment - the Cochrane Collaboration, for example, with the Cochrane Library, and the Centre for Reviews and Dissemination at York with Effectiveness Bulletins and Effectiveness Matters. The Health Technology Assessment programme has taken a little longer to mature because large scale reviews and trials from the process begun in 1994 are only now available.

The first three reviews (two on prostate cancer) have just been published [1-3]. Bandolier is impressed with the results of the two it has read, on prostate cancer. The reviews, while covering similar territory, were done by different teams. Importantly, they reach the same conclusion, that screening for prostate cancer is unproven, and is unlikely to be of any benefit.

In the first Bandolier conference on mens' health , the enthusiastic US attitude about screening was laid out as the key problem in prostate cancer being to screen early enough to find the younger patients who need treatment without frightening lots of normal people. Screening should not be undertaken in old men. A good rule was not to do PSAs on men over 70 "unless they bring both parents with them".

That's fine, but it assumes effectiveness of both diagnosis and treatment. The reviews show just how uncertain are the diagnostic methods (rectal examination and PSA) we have. The active treatment options of radical prostatectomy and radiotherapy both have a significant mortality, and huge morbidity in both urinary incontinence and impotence. For men in their '50s this constitutes a big downside, well laid out in the Effectiveness Matters document from York for men asking for PSA tests (perhaps after reading it some of our enthusiastic journalist docs in the national newspapers may become less enthusiastic). It's an even bigger downside when there seems to be no evidence that the cost can be set against more years of life.

The cost of a full-scale screening programme for the UK is estimated at between £500 million to £1,500 million. It would be money down the drain.

Babies and bathwater

Bandolier has heard it suggested that some Trusts will stop all PSA testing on seeing these reports. That would be a mistake. There are good reasons for using PSA in prostate cancer treatment. It can help make judgements about prognosis and treatment [4].

Getting a copy

Most GPs will have had an information pack with Effectiveness Matters and the superlative companion Effectiveness Matters for patients who might ask for a PSA test. The two monographs are available from the National Co-ordinating Centre for HTA (Fax +44 (0) 1962 877425 at the high cost of £50 each. Bandolier believes these should be on most GPs' shelves, and if enough of you were to express an interest so that a higher print run could be contemplated, the cost would surely drop to something much more affordable.

References:

  1. DM Richards, JJ Deeks, TA Sheldon, JL Shaffer. Home parenteral nutrition. Health Technology Assessment 1997 1: no1.
  2. S Selley, J Donovan, A Faulkner, J Coast, D Gillatt. Diagnosis, management and screening of early localised prostate cancer. Health Technology Assessment 1997 1: no2.
  3. J Chamberlain, J Melia, S Moss, J Brown. The diagnosis, management, treatment and costs of prostate cancer in England and Wales. Health Technology Assessment 1997 1: no3.
  4. RA Moore. Prostate-Specific Antigen. Kaleidescope 4: 1-55 (1994).



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