With November having ended, so too has Movember. During Movember, men sport mustaches to raise vital funds and awareness for men’s health, specifically prostate cancer and male mental health initiatives. While it has no doubt been successful at raising funds and awareness, a record 1.1 million Mo Bros (and Mo Sistas) participated this year, Margaret McCartney wonders in the British Medical Journal if Movember is misleading men, specifically with regards to prostate cancer. In the article several concerns about the message of Movember are cited,
Movember does not just seek to raise money but also to “significantly increase the understanding of the health risks that men face and will encourage men to act upon on that increased understanding.” To do this, men need fair and accurate information. Movember’s emphasis on screening tests, its recommendation of a frequency of screening that is not based on evidence, and its failure to provide good supporting information place well intentioned men in unhelpful conflict with their doctors.
One area that the article takes particular umbrage with is the recommendation from the Movember website of “starting (to screen [PSA]) at age 40-45 is reasonable” – without fully discussing the risks and benefits of testing. Recently, the U.S. Preventive Services Task Force, a nongovernmental panel of independent experts in prevention and evidence-based medicine, recommended doctors stop using PSA tests to screen men with no symptoms of prostate cancer. One of the experts on the panel, Dr. Richard Ablin notes that,
PSA is not cancer-specific; a rising PSA level can be due to an infection or benign prostate enlargement as well as cancer. There’s no PSA level that definitely indicates that prostate cancer is present. And prostate cancer is an age-related disease. Between 40% and 80% of men aged 50 to 75 possess asymptomatic cancer, so cancer may well be found. However, the PSA test can’t distinguish an indolent cancer from an aggressive one.
While proponents of PSA testing point to the 40% decline in prostate-cancer mortality rates since the tests inception in the 1990’s as proof of the test validity, opponents note that better treatments and surgical techniques, healthier patients with longer life expectancies are important factors in those statistics. The task force also concluded that the test can often do more harm than good, citing the rush to treatment (almost all men with PSA-detected prostate cancer opt to receive treatment), which can cause serious side effects from surgery and radiation such as impotence and urinary incontinence. Specifically, for every 1,000 men (aged 55 to 69) who are screed with the PSA test:
- 100 to 120 men would have a false positive test result
- 110 men would be diagnosed with prostate cancer
- 30 to 40 men will develop erectile dysfunction or urinary incontinence, due to treatment
- 2 men will experience a serious cardiovascular event, due to treatment
- 1 man will develop a serious blood clot in his leg or lungs, due to treatment
- 1 man (at most) avoids death from prostate cancer
- For every 3,000 men, 1 man will die due to complications from surgical treatment
It is evident that problems associated with the PSA test are largely associated with the treatment that follows a test result, treatment should never be based on a single PSA test result, especially given that there are so many factors that might impact the results, such as; prostate manipulation during digital rectal examination, transrectal ultrasound, biopsy, a presence of infection, strenuous exercise, ejaculation, normal day-to-day variation, the way that the blood is drawn and stored for testing are just some of the things that may affect the PSA level. The panel concludes their report by noting that better test and better treatment options are needed. However, guidance on those better tests can be difficult to find. Men’s Health describes some of the current screening options, but when all is said an done a PSA is still probably the test that most men will end up getting. And when the PSA test is taken by a man with family history of prostate cancer, or one who is having symptoms it can be a valuable tool, especially if the PSA results are part of an evidence-based monitoring program. Part of an evidence-based PSA screening program , which can better distinguish cancerous vs. benign, and slow vs. fast growing cancers, involves not just getting a PSA number, but looking at such measures as free versus total PSA (the lower proportion of free PSA may be associated with more aggressive cancer), PSA density of the transition zone (a more accurate measure which take the blood level PSA and divides by the volume of the transition zone [the interior part of the prostate that surrounds the urethra] of the prostate), using age-specific PSA reference ranges (PSA levels tend to increase with age), PSA velocity and PSA doubling time (the rate of change in PSA concentration per year), and the Pro-PSA (which encompasses inactive precursors of PSA).
Given that one of the main goals of the Movember campaign is to raise awareness about men’s cancer, it is crucially important that the good information is getting out there and that people fully understand the risks and benefits of PSA testing. Raising awareness is a good thing, especially as pretty much everything we eat (veal, salt, pepper spice, ﬂour, egg, bread, pork, butter, tomato, lemon, duck, onion, celery, carrot, parsley, mace, sherry, olive, mushroom, tripe, milk, cheese, coffee, bacon, sugar, lobster, potato, beef, lamb, mustard, nuts, wine, peas, corn, cinnamon, cayenne, orange, tea, rum, and raisin) is associated, either positively, negatively, but mainly weakly, with cancer.
- Dudes, don’t forget the point of Movember (msnbc.msn.com)
- Prostate Cancer Symptoms (cancercenter.com)
- Canada raised more money than any other country for Movember (ctvnews.ca)