Patients want more prostate screening

My cheerful colleague, The Independent columnist David Aaronovitch, thinks it would be a good idea if we men took more care of our health. In particular he thinks we should follow the example of our American cousins and submit to a digital rectal examination each year to check for prostate cancer.

My cheerful colleague, The Independent columnist David Aaronovitch, thinks it would be a good idea if we men took more care of our health. In particular he thinks we should follow the example of our American cousins and submit to a digital rectal examination each year to check for prostate cancer.

Writing in The Independent last week, he wittily described how the combination of a pushy patient (himself) and a pushy GP had got him an appointment with a consultant urologist for a check-up. Just a check-up, you understand, probably wouldn't reveal anything wrong, but better to be safe than sorry. Who could quarrel with that?

A day earlier, Deborah Orr, writing on the same page, celebrated the dramatic fall in deaths from breast cancer - down by a third in a decade. Advances in treatment had played their part but the crucial factor was increased breast cancer awareness. "The early diagnosis of breast cancer increases the chance of survival by 90 per cent," she wrote. Now, excellent and informative and entertaining as these pieces were, one thing surprised me - the touching faith both columnists showed in the power of doctors to heal, and to prevent ill health. Contrast this with the criticism - not to say, vilification - being heaped on the profession from other quarters. Doctors - how we love them and hate them.

Improving health awareness, for both men and women, is one of the best defences we have against the ravages of disease. But there is a crucial flaw in the claim that screening and early diagnosis lead to longer survival. If you spot a disease at an earlier point in its natural course then you will inevitably survive longer with it, even if you receive no treatment at all.

Early detection of disease may mean only that patients know about it sooner, live longer under its threat, worry a lot more and die at the same time as they would have done had it been detected later. Where is the health gain in that?

This is of key importance in relation to prostate cancer. It is true that prostate cancer is a neglected disease. It causes almost 10,000 deaths a year, a killer second only to lung cancer in men, and not far short of the 13,000 caused by breast cancer in women.

The difference is that breast cancer is treatable. Much of the one-third drop in deaths in the last decade is attributed to the success of the hormonal drug, tamoxifen. Its effect has been so dramatic scientists are now starting to talk of a "cure" for breast cancer.

For prostate cancer, by contrast, there have been no new treatments, and men who require removal of the gland rely on the skill of the surgeon. Experts in prostate surgery are in short supply, and more than half of men find themselves impotent after the operation, while between 6 and 40 per cent of patients - estimates vary - are left incontinent to some degree. That is a high price to pay for treatment of uncertain benefit.

The key point about prostate cancer is that in many men it is slow-growing, and those who do nothing may survive for years, or even decades, to die of something else. That is why the Government has so far refused to introduce prostate screening. In the current state of knowledge, it would merely condemn men diagnosed to live longer under a threat of disease that may turn out to be empty. While Americans are much keener on screening for and treating prostate cancer, there is no evidence so far that their survival rate is better than ours.

The most telling finding is that from an American study of elderly men offered surgery, who were given a video setting out what the operation involved, highlighting the risks and the benefits. After viewing it, 90 per cent of them opted for "watchful waiting".

Early diagnosis can, certainly, save lives. But it is not a universal truth. Medical treatment carries risks and these need to be carefully weighed against the likely benefits. Just as not all doctors are ogres neither are they, always and in every case, saviours. The treatment can be worse than the disease.