Parallel to breast screening, prostate screening: overdiagnosis, as well!

As for breast cancer screening, there is a similar problem with prostate cancer screening.

While there is still a controversy regarding breast cancer screening, as far as prostate screening is concerned, we have crossed this step.

Official recommendations are that mass screening should no longer be offered to men. Yet it is still advocated, in particular by our urologist colleagues.

Philippe Nicot explains in The Conversation, in an article published on November 15, 2016, a summary of the ins and outs. :

https://theconversation.com/prostate-attention-a-lexamen-de-trop-68756

We publish it again here, following the guidelines for republishing issued by The Conversation.

Prostate: beware of over-examination!

Philippe Nicot, University of Limoges

We learn an important news, in the November 15 issue of the weekly scientific publication of Santé publique France. The institution in charge of monitoring diseases in our country slips, with a glint of suspicion, that health authorities have revised their instructions on screening for prostate cancer, the most common cancer in men over 50 years of age. And this on the basis of scientifically founded information. In particular, they are encouraging doctors to prescribe less the blood test that has long served as a justice of peace in deciding whether or not to remove this gland from male genital tract. A small revolution.

 Health authorities are finally opening their eyes to an inadequate practice that has been known and reported by many experts for nearly three decades. Prostate cancer is usually detected by dosage of a protein produced by cells of prostate gland, PSA, or prostate specific antigen (PSA), from a simple blood test. This low molecular weight glycoprotein is one of the constituents of semen, serving to fluidify it and facilitate sperm motility. Some of it passes into bloodstream. Its production is linked to the activity of prostate. In a blood test, a rise in PSA levels is interpreted as an indication of a possible tumor.

In the Weekly Epidemiological Bulletin (BEH) that Santé publique France (formerly the Institut de veille sanitaire) focuses on prostate cancer, the editorialists are prominent guests: the President of the National Cancer Institute (Inca), Norbert Ifrah, associated with the Director General of Santé publique France, François Bourdillon. They note that PSA testing is, according to data from the French National Health Insurance, practiced very frequently. "In 2015, 48% of men aged 40 and over had taken a PSA test in the previous three years, with this frequency rising to 90% for men aged 65 to 79," they say.

However, this analysis in men who do not complain of any signs suggestive of cancer is not recommended in 2016 by "any health agency or authority in the world," they write clearly, neither in a screening program for this cancer, nor at the individual initiative of the doctor. In other words, there is a big gap between official references and practice.

No established effect on mortality

Today, we have necessary hindsight to answer the only valid question: has the generalization of this examination reduced the mortality related to this cancer? The assessment drawn up by the National Cancer Institute (Inca) in 2015 states that it has not.

Two randomized trials conducted in the U.S. and Europe that evaluated the impact of a PSA prostate cancer screening program on specific prostate cancer mortality have produced contradictory and questionable results," writes the health agency. "Their meta-analysis did not show a significant effect in terms of a decrease in mortality from prostate cancer, which does not support a conclusion in favor of a benefit at a population level".
The test also has many disadvantages. It detects cancers that, for some, progress so slowly that regular monitoring would be preferable to surgery - only they cannot be distinguished with confidence yet. The test also has many disadvantages. It detects cancers that, for some, progress so slowly that regular monitoring would be preferable to surgery - only it is not yet possible to distinguish them with certainty. The test poses a high risk of overdiagnosis and overtreatment," says Inca. It detects many cancers that would have remained asymptomatic without having the means to identify cancers that do not require treatment. However, surgery can have serious consequences, rendering the man impotent or incontinent. "The treatments are effective, but their undesirable effects can be significant, while keeping an acceptable quality of life must be taken into consideration," adds Inca.

Based on this observation, Inca took action - without any fanfare - with general practitioners, the main prescribers of this PSA dosage. The agency elaborated with the College of General Medicine documents to allow the National Health Insurance Fund for Employees (CNAMTS) to exchange on this subject with general practitioners. The objective: to make this examination, soon, no longer automatic.

Mass screening not recommended

The PSA assay has been a controversial issue in France since 1989. That year, a "consensus conference" was held in a state-of-the-art manner. Organized by three urologists, Professors François Richard, Guy Vallancien and Yves Lanson, and the economist Laurent Alexandre, this consultation of experts already concluded that "the organization of mass screening for prostate cancer is not recommended".

A new consensus conference is held in 1998 and the same year, a clinical practice recommendation states even more clearly: "Since prostate cancer screening (whether mass screening, directed at the entire interested population, or opportunistic, on a case-by-case basis) is not recommended in the current state of knowledge, there is no indication to propose a PSA dosage in this context. »

Visual of the first National Prostate Day in 2005 by French Urology Association

But then a grain of sand slips into the system. The majority of learned societies and professional groups around the world rule against such screening, except for three American associations (American Cancer Society, American Urological Society, American College of Radiology). Shortly afterwards, the French Association of Urology (AFU), which brings together experts in male reproductive system, launches in its turn what can be described as a campaign to promote PSA testing.

In 2009, however, two major studies, one American and one European, brought the scientific debate to a close. The French National Authority for Health (HAS) concluded: "No new scientific element is likely to justify re-evaluating the advisability of setting up a systematic screening program for prostate cancer using PSA testing. "End of story.

The American physician who developed the dosage in 1970, Richard Albin, is himself concerned about the "public health disaster" caused by his discovery. In an op-ed published in 2010 in the New York Times, he wrote:

”I never dreamed that my discovery four decades ago would lead to such a profit-driven public health disaster. The medical community must confront reality and stop the inappropriate use of P.S.A. screening. Doing so would save billions of dollars and rescue millions of men from unnecessary, debilitating treatments”

A risk of impotence

In 2011, an American authority, the US Preventive Service Task Force (USPSTF), recommends stopping prostate cancer screening with PSA, emphasizing its side effects. For every 1000 people treated, there are 5 premature deaths one month after surgery, between 10 and 70 patients with serious complications but survivors. Radiotherapy and surgery have long-term effects, and 200 to 300 patients will become impotent and/or incontinent.

In addition, there are deaths following prostate biopsy, a far from insignificant procedure. A French study of 2010 conducted by Paul Perrin reports an alarming figure: 2 per 1000.

Today, France has officially ended the systematic use of PSA testing. And the health authorities have decided to rely on general practitioners to change mentalities and practices.

How do you explain the fact that GPs have not taken the lead? Because they are misinformed, no doubt. Because patients are asking them to do the exam, too. The Inca suggests it in its synthesis on the benefits and risks of screening. "According to surveys, one out of every five men over 60 years of age takes the initiative to be screened for prostate cancer," the agency writes. The analysis of practice of general practitioners shows that, torn between the contradictory recommendations of health institutions and several learned societies and sometimes confronted with a strong demand from patients, general practitioners are rather inclined to propose or prescribe a PSA dosage to their male patients. » The time counted, in a consultation, certainly plays a role. Speaking on France Inter in 2011, the general practitioner Dominique Dupagne summed up the problem in a striking formula: it takes 15 seconds for the doctor to explain that this screening should be done, and 30 minutes to explain that it should not be done.

What is the role of urologists?

If it is legitimate to mobilize general practitioners to prescribe the PSA dosage more effectively, what about urologists? Surprisingly, they are not integrated into strategy of health authorities. In order to understand this, it is necessary to look back at the confrontation that has been taking place on this subject for more than twenty years between urologists on the one hand, and epidemiologists and general practitioners on the other.
As early as 1994, the independent medical journal Prescrire testifies to the exchanges between the general practitioners who are members of their editorial staff and the urologist Bernard Debré. The former minister and member of parliament strongly defended screening and stated: "Medical references will come, they will decide that PSA is a fundamental examination after 50 years. "For general practitioner Jean-Pierre Noiry, "this opinion is in complete contradiction with the results of available studies and consensus recommendations".
Thereafter, the tone will not stop rising. Researchers specializing in epidemiology and public health, such as Catherine Hill, Alain Braillon and Bernard Junod, are stepping up to the plate in violent face-to-face encounters with urologists urging the prescription of PSA dosage. Christophe Desportes, a general practitioner in Finistère, in his book Prostate, the big sacrifice (Editions Pascal) tells how in 2005 he challenged a fellow professor of urology, and was retorted: "We're going ahead while waiting for proof of usefulness to be provided". A gamble as daring as that of administering a drug before knowing what it is used for?

Visual of the campaign Touche pas à ma prostate (Don't touch my prostate), launched on the Atoute.org website in 2008.

A committed general practitioner and administrator of a patient community website, Dominique Dupagne decided to publicly call for a moratorium on his website: "Don't touch my prostate! "The watchword circulated among GPs and beyond. But in the field, the battle is far from being won. Urologists have spread, by their authority, the idea that this screening should be carried out from the age of 50. Many patients are adhering to it. As for general practitioners, most follow. Either because they agree with the opinion of specialists, or because they are afraid of a lawsuit brought by a patient. Their fear is fueled by the legal ordeal suffered by a colleague, Pierre Goubeau, prosecuted for not having prescribed a PSA dosage. This general practitioner based near Troyes will finally emerge victorious from a case that will drag on from 2008 to 2015.

No logo of the Urology Association

Today, urologists appear to be the major absentees of the national action that is about to take place. The French Association of Urology (AFU) will not appear on the documents that will be distributed to general practitioners by the Health Insurance. According to Inca, "when consulted, the AFU did not wish to put its logo on the doctor's document, because it felt that the repercussions of this document present the risk of an irrational failure to use the PSA dosage, and of a regression in the stage of revelation of prostate cancers and their survival rates. »

One might think that urology specialists do not wish to see a substantial decrease in their activity. However, this would be reductive. It should not be forgotten that these colleagues are confronted with the difficult image of patients suffering from cancers in serious forms, particularly with bone metastases. I think, having discussed with many of them, that this proximity to the most seriously affected patients makes them hermetic to scientific data that seem far removed from their own experience. If Health Insurance wants to see its action succeed, it will also have to unravel all the threads of the representations of this disease among urologists.

Being too often involved in public health debates, we forget an actor far from playing a marginal role: credit insurers.

Through a quick search on the Internet, I was able to verify that many of them ask for this test before accepting the subscription for men over 46 years old. While it seems legitimate for insurers to seek to limit the risk of default for their clients, they cannot tolerate exposing them unnecessarily to significant side effects.

The public health action plans to "provide men aged 40 and over with balanced information on the advantages and disadvantages of screening to enable them to make an informed decision". If I may make a suggestion, given the possible consequences on sexual activity and couple life, I would suggest that spouses or partners also be involved in the decision.

Philippe Nicot, teaching general practitioner, University of Limoges

The original version of this article was published on The Conversation.

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