Volume 193 - Issue 7
Has PSA testing truly been a "public health disaster"?
Authors: Simon Chapman and Alexandra Barratt
Med J Aust 2010; 193 (7): 431. || doi: 10.5694/j.1326-5377.2010.tb03988.x
Published online: 4 October 2010
Published online: 4 October 2010
To the Editor: Costello and Murphy’s lament1 about the discoverer of prostate-specific antigen (PSA), Richard Ablin, describing PSA testing as a “hugely expensive public health disaster”2 contains several egregious claims that require correction. They write that “since the introduction of PSA testing in the 1980s, we have seen a 25% reduction in mortality” from the disease.
Thirty years ago (in 1980), before PSA testing was possible, the age-adjusted mortality rate from prostate cancer in Australia was 33.4/100 000. In 2007, it was 31.0/100 000, a decline of 7.2%. Over the same period, prostate cancer incidence rose 110%, from 80.8/100 000 to 170/100 000,3 thanks to the aggressive promotion of PSA testing. Recent New South Wales data show that 3 years after radical prostatectomy, 77.4% of men are impotent and 12.3% have urinary incontinence, compared with 22.3% and 1.0%, respectively, of controls.4 Many of these men are, to use Costello and Murphy’s word, “overtreated”1 — they underwent unnecessary surgery and now live with the consequences. From a 2009 European trial,5 the take-home message for a man being tested today is:
There is a one in 50 chance that, in 2019 or later, he will be spared death from a cancer that would otherwise have killed him. And there is a 49 in 50 chance that he will have been treated unnecessarily for a cancer that was never a threat to his life.6
This is what Ablin called a public health disaster.
With reference to this European trial,5 Costello and Murphy claim that “PSA testing has led to greatly reduced mortality”. This “great reduction” was from 4.2 to 3.3 deaths per 10 000 person-years.
Costello and Murphy propose that “those with a PSA level well below the median for men in their 40s . . . (the vast majority at this stage) could be reassured . . .”, but below the median lie half the men, not the vast majority. This policy would mean that the other half of men aged 40 (not the small minority, as implied by Costello and Murphy) would be above the threshold. They would not be reassured; presumably they would be offered more frequent testing and follow-up. Labelling half the population of men aged 40 as higher risk has enormous implications for the men (anxiety, inconvenience, cost) and the health system that would be called on to fund more appointments and tests. Such a proposal does indeed sound like a public health disaster.
Competing interests
Simon Chapman has received payment as a Board Member of Cancer Australia. His comments here do not necessarily reflect those of Cancer Australia.
References
- Costello AJ, Murphy DG. Has PSA testing truly been a “public health disaster” [editorial]? Med J Aust 2010; 193: 4-5. 0_CBBHDDBD
- Ablin RJ. The great prostate mistake. New York Times 2010; 9 Mar. http://www.nytimes.com/2010/03/10/opinion/10Ablin.html (accessed Jul 2010).
- Australian Institute of Health and Welfare. Cancer — Australian cancer statistics update, May 2010. http://www.aihw.gov.au/cancer/index.cfm (accessed Jul 2010).
- Smith DP, King MT, Egger S, et al. Quality of life three years after diagnosis of localised prostate cancer: population based cohort study. BMJ 2009; 339: b4817. 0_i1095421
- Schröder FH, Hugosson J, Roobol MJ, et al. Screening and prostate-cancer mortality in a randomized European study. N Engl J Med 2009; 360: 1320-1328. 0_pgfId-2134512
- Kolata G. Prostate test found to save few lives. New York Times 2009; 18 Mar. http://www.nytimes.com/2009/03/19/health/19cancer.html (accessed Jul 2010).