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Active Living
Full Listing with story descriptions
A Healthy Balance
Ankle Sprains
Active Kids, Healthy Kids
Active Kids in Winter
Athletic Skin Infections
Children, Nutrition & Exercise
Beat the Heat!
Cold Weather Workouts
Concussions
Core Stability
Cross Country Skiing
Exercise and Disabilities
Exercise and Menstrual Irregularities
Exercise in the Cold
Exercise in the Heat
Exercise is Medicine
Exercise Options
Exercising in Pregnancy
Female Athletes
FITT Prescription
Footwear for Running
From Surviving to Thriving
Flexibility
Gadgets & Gizmos
Get Moving!
Get Motivated
Golf Exercises
Golf Injury Prevention
Head Injuries
Hockey Injuries
Home Gyms
Immunization
Jump Start Weight Loss
Knee Cap Pain
Knee Ligament Injuries
Live Actively
Low Back Pain
Osteoporosis & Exercise
Osteoarthritis
Osteoarthritis of the Knee
Plantar Fasciitis
Prehistoric Workout
Prevention of Sports Injury
Proprioception
Recreational Safety Equipment
Running
Safe Snow Shovelling
Shin Splints
Ski Conditioning
Shoes & Fit
Sore Elbow
Sore Shoulder
Spinal Cord Injuries
Staying Active
Staying Fit in the Cold
Sports Nutrition & Supplements
Strength Training
Swimming Injuries
Teen Sports Injuries
Walking
Water and Exercise
Weight Training
7 Wonders of Walking
Adolescent Health
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Acne
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Adolescent Growth & Development
Body Image
Body Piercing
Bullying
Chronic Diseases in Teens
Communications Skills
Concussion in Sport
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Dangers of Artificial Tanning
Depression
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Female Physical Exam
First Period
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Junior High
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Mononucleosis
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Teens & Exercise
A Woman's Physical
Your First Job
Youth Violence
Childbirth
Full Listing with story descriptions
Advice from the Maternity Clinic
Advice from the Maternity Clinic (Part 2)
Alcohol in Pregnancy
Building a Better Baby
Birthing Etiquette
Birth Plans
Birthing Procedure Trends
Bleeding in Pregnancy
Breastfeeding Benefits
Caesarean Section by Request
Care for the New Mother
Cord Blood Banking
Delaying Motherhood
Blue after Baby or Postpartum Depression
Diabetes in Pregnancy
Eating Well for Pregnancy
Evolving Ideas about Pregnancy and Birth
Exercise in Pregnancy
Flying During Pregnancy
Folic Acid in Pregnancy
High Blood Pressure in Pregnancy
Getting a latch on breastfeeding
Group B Streptococcus
Induction of Labour
Infections During Pregnancy
Intrauterine Growth Restriction (IUGR)
In-Vitro Fertilization
Low Birth Weight Babies
Medication & Pregnancy
Miscarriage
Managing Your Own Labour
Monitoring Your Labour
Nausea & Vomiting in Pregnancy
Pain Relief in Labour
Prenatal Classes
Preterm Labour
Planning a Pregnancy
Pregnancy Weight
Prenatal Care Providers
Postpartum Repetitive Strain Injuries
RH Disease
Rupture of Membranes Before Labour
Sex During Pregnancy
Skin Changes in Pregnancy
Smoking and Pregnancy
Support During Labour
Travelling While Pregnant
Ultrasound for Fun & Photos
Natural Remedies in Pregnancy
Vaccinations During Pregnancy
Vacuum & Forceps for Delivery
Vaginal Birth After Caesarean
When Baby Comes Home
Childhood
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Asthma in Children
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Babysitter
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Children's Headaches
Childhood Obesity
Choosing A Babysitter
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Developmental Milestones
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Daytime Wetting
Introducing Solid Foods
Developmental Co-ordination Disorder
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Feeding Your Baby
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Hearing
How Children Grow
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Heart Murmers
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Influenza
Iron
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Children and Sports Injuries
Lazy Eye (Amblyopia)
Learning Disabilities
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Not Just Baby Fat
Orthodontics
Preparing for Lab Tests
Recognizing Learning Disabilities
Red Rashes
RSV-Childhood Respiratory Virus
Safe Summer Fun
School
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Sick Toddler
Sleep Struggles
Sniffles, Fevers, Rashes & Coughs
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Toddler Safety
Thumbsucking
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Tummyache
Urinary Tract Infections
Vaccinations
Vaccination and Autism
When to go to the Doctor
Whooping Cough
Worried Sick
Yeast Infections in Children
Chronic Pain
Full Listing with story descriptions
Introduction
Managing Your Pain
Movement Matters
Moving Forward
Nutrition
Opioids
Pacing
Pain Medications
Prevention
Returning to Work
Understanding and Goal Setting
When Pain Doesn't End
Dental Health
Full Listing with story descriptions
Antibiotics and Dental Surgery
Baby Bottle Tooth Decay
Baby Teeth
Bad Breath (Halitosis)
Children's Dental Injuries
Choosing a Dentist
Cosmetic Dentistry
Mouth Guards
Dental Exam
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Dental Care Offshore
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Dentures and Healthy Jaw
Esthetic Dentistry
Fluoride
Fluoride Findings
First Dental Visit
Headaches
A Healthy Mouth
Healthy Mouth, Healthy Body
Jaw Joint and Muscle Problems
Keeping it Clean
Laser Use in Dentistry
Mouth Protection Equipment
Oral Cancer Screening
Oral Healthcare
Oral health and long term care
Oral Health Care Products
Orthodontics
Orthodontist First Visit
Painless Dentistry
Periodontal Disease
Removable Dentures
Root Canal
Seniors Oral Care
Sensitive Teeth
The Smile You Want
Sore Mouth, Aching Jaw
Snoring and Sleep Apnea
Smiling through the Senior Years
Teeth for Life
Temporomandibular Disorders (TMD)
Tobacco Risks to Oral Health
Tongue Piercing
Tooth Whitening
Travel Dentistry
Water Fluoridation
Wisdom Teeth
Your Healthy Smile
DIABETES
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10,000 Steps
A1C Test
Accurate Blood Glucose Testing
Alchohol and Diabetes
A Diabetes Success Story
ABCs of Diabetes Management
Alternate Site Testing
Artery Health
ASA Therapy
Benefits of Insulin
Benefits of Breakfast
Blood Glucose Medications
Blood Glucose Myths
Blood Glucose Testing
Blood Glucose Testing Tips
Blood Sugar Lows
Blood Glucose Monitors
C-Peptide Testing
Canada Food Guide Revisited
Carbohydrate Counting
Catastrophic Drug Plan
CDA Guidelines for Diabetes
Celiac Disease and Diabetes
Childhood Diagnosis of Diabetes
Children and Type 2 Diabetes
Cholesterol-lowering Medications
Colds and Diabetes
Constipation
Continuous Blood Glucose Monitoring
Cutting Edge
Debunking Diabetes Myths
Driving and Diabetes
Diabetes and Menopause
Diabetes and OTC Medications
Diabetes Care Team
Diabetes and Celiac
Diabetes and Depression
Diabetes Diet
Diabetes Eating on a Shoestring Budget
Diabetes Etiquette
Diabetes and Oral Health
Diabetes and Thyroid Disease
Diabetes and Your Mouth
Diabetes and Your Eyes
Diabetes in Cats
Diabetes in Dogs
Diabetes Management ABCs
Diabetes Meter Technicians
Diabetes Myths
Diabetic Ketoacidosis
Diabetic Retinopathy
Diet Tips for South Asians
Dining Out
Drinking and Diabetes
The Discovery of Insulin
Eating Disorders
Easing the Strain of Stress
Eating to Protect Your Kidneys
Eggs in a Diabetic Diet
Emotional Eating
Emotions of Diabetes Diagnosis
Erectile Dysfunction
Exercise Excuses
Why Fad Diets Fail
Fats
Fibre
Fill Your Day with Energy
Financial Support for Diabetes
Food Temptation
Foot Care
Footwear and Foot Health
Fruits and Veggies
Gastroparesis
Gestational Diabetes
Get Active
Get Physical
Gift Ideas
Glycemic Index and Glycemic Loads
The Glycemic Index
Going Green in the Kitchen
Grocery Shopping Tips
Guidelines for Diabetes Management
Holiday Party Survival Guide
Health Information on the 'Net
Healthy Happy Holidays
Healthy Beverage Choices
Health Benefits of Soy
Healthy Restaurant Meals
High Blood Pressure and Diabetes
High Blood Pressure
HbA1c Test
Healthy Eating for Active People
High Blood Lipids
Home from the Hospital
Home Alone and Sick
Hypoglycemic Unawareness
Impaired Glucose Tolerance
Immunization & Diabetes
Incretins-a Hormone Treatment
Injecting Insulin
Insulin Discovery-The Story
Insulin
Insulin Handling
Insulin - the Key to Energy Management
Insulin Pumps
Insulin Pen Needles
Insulin Pump Infusion Sets
Insulin Pump Therapy
Immunization and Diabetes
Internet Health Sites
Islet Cell Transplantation
Insurance
Ketones
Kidney Disease - Reducing the Risk
Living with Diagnosis of Diabetes
Living Powerfully with Diabetes
Low Blood Glucose
Managing Diabetes
Managing Blood Glucose
Metformin
Nutrition Food Labels
Meal Planning
Your Medication Expert
Medication Research Studies
Metabolic Syndrome
Microalbuminuria
New Diabetes Technologies
Natural Medicines and Diabetes
No Need for Insulin?
Not Snoozing
Over-the-Counter Medications
Oral Health and Diabetes
Osteoporosis and Diabetes
Diabetes and OTC Medications
Pedicure Precautions
Peripheral Arterial Disease
Pet Diabetes
Planning for Pregnancy
Prebiotics and Probiotics
Preparing for Activity
Putting off Insulin
Reducing Stress of Surgery
Safe and Successful Travel
Schizophrenia and Diabetes
Sensible Snacking
Setting Health Goals
Setting Goals for Physical Activity
Sharps Disposal
Shorter Insulin Needles
Sleep - a Missing Link
Smart Snacking
Smart Summer Nutrition
Snack Bars
Snacking with Diabetes
Sodium
Social Media & Diabetes
Solving the Insurance Puzzle
Stress and Diabetes
Success in School
Supplements
Supporting Spouse with Diabetes
Sweeteners
Sugar, Carbs and Blood Glucose Control
Think Positive with Diabetes
Tiny Bites Equal Big Calories
Traveling with Diabetes
Tips for a Better You
Tobacco Use and Diabetes
Top 10 Reasons to Exercise
Treating Low Blood Glucose
Treating Hypoglycemia - Role of Glucagon
Tune up Your Diet
Type 1.5 Diabetes
Type 2 Diabetes
Understanding Diabetes
Understanding Diabetes Medications
Understanding Ketones
Used Sharps
Urinary Incontinence
Vacationing with Diabetes
Vegetarian Eating for Diabetes
Vitamin D
Walking
Wise Choices About Natural Medicines
Wonderful Water
Natural Medicines & Diabetes
World Diabetes Day
Your Medicine Cupboard
Zimbabwe Hand Jive
Family Medicine
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ADHD in Children
Allergic Rhinitis
Allergies
Antibiotic Use
Arthritis
Aspirin Every Day?
Asthma
Back Pain
Back Pain Myths
Back Pain - Lower
Birth Control
Bladder Problems
Blood Transfusions
Breaast and Prostate Cancer Screening
Carpal Tunnel Syndrome
Check-Up
Colon Cancer Screening
Contact Lenses
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COPD
Cost of Doctor's Visit
Diabetes Management
Diarrhea
Diagnostic Tests
Do I Need a Bone Density Test?
Doctor Visit
Driving Vision
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Dealing with Dry Eyes
Does My Sore Knee Require an MRI?
Do I Need an Annual Physical?
Eczema
Electronic Medical Records
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Family Doctor
Fibromyalgia
Floaters and Flashes
Food Poisoning
5 Ways to Stay Healthy
Gallbladder
Get Active!
Glare
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Healthcare Teams
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Human Papilloma Virus
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How to Talk to Your Doctor
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Medical Digital Technology
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Opioid Myths
Primary Healthcare Reform
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Restore Your Core
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Stroke
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Win by Losing
Urinary Tract Infections
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First Aid
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Bites and Stings
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First Aid Travel Kit
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Growing Older
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Get Active!
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Have Health, Will Travel
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Modern Living
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Barbecue Basics
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Bisphenol A
Canada's New Blood System
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Diabetes Epidemic
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Swim to Survive
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5 Tips to Manage Weight
10 Ways to Cut Down on Fat
Battle the Bulge
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Breakfast is Important
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Diet Reality Check
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Feeding Your Kids
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Food Chemistry 101
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All Words Any Words Phrase
Family Health Magazine - FAMILY MEDICINE

Breast and Prostate Cancer Screening Recommendations
Exploring the controversy

Many people are confused by recent recommendations to screen less often for breast and not to screen for prostate cancer. Those who have had cancer found and treated through these tests defend their value. The idea of finding such a disease early is appealing, and makes recommendations to delay or omit screening hard to understand.

Why the controversy?

Some people are concerned that the new recommendations (see sidebars) are designed to ration care and reduce health costs. As a volunteer member of the Canadian panel, who also attended U.S. panel meetings, I can assure you that this is not the case. Panel members are not paid. Their focus is on how these tests can best help people.

So why is there such a split of ideas? One major reason is that people diagnosed and treated early believe that they have been cured. They are grateful to the test and the doctors who treated them. However, the situation is actually more complicated.

About cancer

To understand this complex question, it helps to understand a little about cancer and how it may grow.

Not all cancers are the same. Any given type of cancer has a range of growth patterns. Some grow very fast, invade rapidly, spread through the body and kill within a short time. Others grow so slowly that they might cause death by the time a person reaches extreme old age (well over 100). Some grow at intermediate speeds.

As well, some cancers can be treated using current methods, while others cannot. Some are treatable even if discovered late. Others will kill even if found really early. Most cancers occur late in life, and many of these grow slowly. However, a few start in young people, and sadly more of these grow rapidly.

For instance, consider cancer of the cervix. This cancer is found in women, usually after age 40. It is highly treatable when caught early. A Pap smear test scrapes cells directly from the top layer of skin on the cervix, where cancer changes occur. Using this test to find really early changes can lower the death rate by 70 per cent or more.

While this cancer is rare among young women, it tends to be worse for them and more difficult to cure. Even though the Pap smear is a good early test, some women still die from the disease. Many early changes (pre-cancers) are found before they develop into cancer. Left alone, these heal themselves in many women. However, all women are treated to make sure that any cancers are prevented from developing. Perhaps three times more women with early pre-cancer changes are treated than would get cancer, to be sure that none do. Some get complications from the treatment, such as infection or an incompetent cervix, which can lead to pregnancy loss later on.

Balancing the harm and benefit of early testing and treatment is always necessary. With cervical cancer, testing is done in the hope that preventing invasive cancer outweighs the risk of harm, such as miscarriage or premature birth. If changes are not found at the pre-cancer stage, only about 1.5 per cent of women would get cancer of the cervix. If we did not use pap smears, maybe one per cent of women would die from it. Pap smears are offered to all women between 21 and 65, even though over 48 out of 50 women will never benefit from the test.

Most other types of cancer are more difficult to detect early and to treat.

An issue to consider is the potential for error. Cancer at an advanced stage is easy to diagnose. With early cancers, in contrast, cells under the microscope or shadows on an X-ray barely differ from normal ones. It is very hard to decide whether the cells are abnormal or whether they are just a variation of normal. There are many more samples with slightly abnormal cells than severely abnormal ones.

Pathologists are doctors who look at body tissues and cells to check for disease. They have very difficult decisions to make about whether to call a specimen cancer or not. They know lives depend on their analysis. Pathologists often call in other doctors to assist with difficult decisions, but even with agreement, they may still be wrong. Radiologists who read X-rays face similar situations.

Interestingly, 'abnormal' may differ from country to country. British radiologists usually call about five per cent of mammograms abnormal, while in North America, up to 10 per cent may be called abnormal. A tiny percentage of the extra women that North American radiologists call abnormal have cancer, and would be 'missed' by British radiologists.

Breast cancer

Canadian Task Force on Preventive Health Care Breast Cancer Screening Guideline

Nov. 2011

Mammography

  • For women aged 40 to 49, routine screening with mammography is not recommended.
  • For women aged 50 to 69, years routine screening with mammography every two to three years is recommended.
  • For women aged 70 to 74, routine screening with mammography every two to three years is recommended.

Magnetic Resonance Imaging

  • Routine screening with magnetic resonance imaging is not recommended.

Clinical Breast Exam

  • Routinely performing clinical breast exam alone or in conjunction with mammography to screen for breast cancer is not recommended.

Breast Self Exam

  • Women should not be advised to routinely practice breast self exam.

Early detection of breast cancer is difficult. The most effective method is mammography, an X-ray of the breast. This test often shows early changes, such as small clumps of calcium, which can be seen by expert radiologists. A biopsy, usually done by inserting a fine needle into the area of change and sucking out cells, may be the next step. The cells are studied under a microscope. If possible cancer cells are seen, surgery may be needed to take out the lump. Cells from the lump will be checked under the microscope. If the pathologists see what they think are cancer cells, further treatment is done. This could involve major surgery, radiotherapy or chemotherapy.

As X-ray is an indirect method of testing, breast cancer is more difficult to find than cervical cancer. Generally, the cancer must be larger to be seen. Even so, for women between 50 and 70 years, screening by mammography reduces death rates by 15 to 20 per cent, or 33 per cent in the highest estimates. Mammography does not help most women who get breast cancer. Some studies show a smaller benefit among women aged 40 to 49, but this is disputed. It is not clear whether there is any value in screening at this age. Even worse, far more women are diagnosed as having some abnormality than would ever get cancer.

Table 1 shows the results of a study from Australia, comparing women who were screened with those who were not. For each age group, the table shows what happens over ten years when 1000 women are screened. At each age, a large proportion of the women had a positive mammogram. This means that some abnormality was noticed. Further tests were done for those women, and a few were diagnosed as having cancer. With women who were not screened, fewer were diagnosed as having cancer. So, screening created a large amount of over-diagnosis, meaning diagnosis of cancer in women who would never develop invasive cancer if left alone. The trouble is that all these women are given the full treatment – surgery, radiotherapy and chemotherapy. Many women still die in spite of the screening. Still, there are fewer deaths among screened women, so some lives are 'saved' by this process.

Table 1: Outcomes of Mammography from Australian study

What proportion of breast cancer deaths can be reduced by mammogram screening? The best estimate is 30 per cent. This table shows ten-year biennial results per 1000 women.

Age 40-49 50-59 60-69 70+
Recalls 251 242 185 167
Diagnosis of cancer 21 33 38 41
Overdiagnosis 7.5 13 14 15
Lives saved .5 1.9 3 2.2
Number needed to save one life 2000 500 333 400

At each age, there is a trade-off between the possible benefit in lives saved, against the harm to those told they have cancer and treated for it unnecessarily. Here is the dilemma — most women who are 'survivors' of breast cancer had that diagnosis because their cells looked like cancer under the microscope. However, they would never have developed disease that would grow, spread and cause death.

Women have to decide whether this trade-off is a good choice for them, and at what age they would like to start mammography screening. This is a difficult decision with no right answer.

Prostate cancer

The situation with prostate cancer is similar. Although a test called the prostate specific antigen (PSA) is available, it is generally recognized as a poor test. It finds many false positives, but misses many men with prostate cancer. The follow-up test is prostate biopsy. This is a series of tissue samples taken from the prostate gland with a needle. Samples are examined under the microscope. Deciding whether prostate biopsy samples contain cancer is also difficult, since cancers are common. Over 40 per cent of men aged 60 have them, but most are very slow growing, and would never kill the man before he dies of something else.

Screening for Prostate Cancer:
Review for the U.S. Preventative Service Task Force Nov. 2011

Draft Recommendation: Do not screen for prostate cancer, with either PSA (Prostate Specific Antigen) testing or rectal examination.

Review of the trials performed to test the value of screening show that PSA screening results in small or no reduction in deaths from prostate cancer, and can cause harm, including post-operative death (0.5 per cent), cardiovascular events (0.6 per cent to 3 per cent) and one in five who have a surgical prostatectomy will have continuing incontinence of urine.

National Cancer Group Recommendations

Canadian Cancer Society
Prostate cancer can be detected early using a PSA test and a digital rectal exam. However, research does not clearly show if the benefits of testing for prostate cancer outweigh the harms. We recommend that you talk to your doctor about your risk for prostate cancer and about the benefits and harms of early detection.
Read more: tinyurl.com/7sdebqh

American Cancer Society
Research has not yet proven that the potential benefits of testing outweigh
the harms of testing and treatment.
The American Cancer Society believes that men should not be tested without learning more about what we know, and don't know, about the risks and possible benefits of testing and treatment.

UK: NHS Screening Committee
The National Screening Committee has recommended that a national screening program not be introduced at this time.
The Prostate Cancer risk management program was introduced so that men who ask about a PSA test can make an informed choice, based on quality information about the advantages and disadvantages of testing.

Cancer Council Australia Position Statement (May 2010)
Current evidence indicates that the PSA test is not suitable for population screening, as the harms outweigh the benefits.

Canadian Task Force on Preventive Health Care, CTFPHC Recommendation for Screening for Breast Cancer with Mammography. Retrieved January 24th, 2012. (See www.canadiantaskforce.ca)

A few organizations, mostly in North America, strongly urge men to start screening at age 40. However, the majority of cancer expert organizations around the world remain doubtful.

Several trials have now been done to test this screening process. Each has its strengths and weaknesses. The best one was done at several different centres in Europe (the Economic and Social Research Council or ESRC trial). It showed that for men between 55 and 75 years, doing one test every three to four years reduced prostate cancer deaths by 20 per cent. That sounds good, but 10,000 men screened every three to four years will have 34 fewer deaths after 14 years from prostate cancer, but no difference in total deaths. In other words, they will die of something else.

Table 2 compares what happened among 10,000 men screened in the ERSC trial, compared to the same number who were not. The number of men harmed is shown in the net benefit column as negative numbers. This does not include harm to men treated with either chemotherapy or hormone therapy, which is likely in North America as treatment is more aggressive here than in Europe.

Table 2: Effects of Prostate Screening from Canadian Partnership against Cancer

Estimate of effects experienced by 10,000 men aged 55–69 years, each screened every 4 years, compared with those not screened. All were followed for 9 years.

  Screened Not Screened Net Effect Net Benefit Net Harm
Number invited for screening/not screened 10,000 10,000      
Number Number of positive PSA results (> 3 ng/ml) 1of positive PSA results (> 3 ng/ml) 1
1,620        
Number of biopsies 1 1,393        
Number of cancers detected 1 820 480 + 340    
Number of potentially aggressive cancers (Gleason score > 7) 1 228 217   11  
Number of low-grade cancers
(≤ Gleason score 6) 1
592 263     329
Number undergoing radical prostatectomy 2 220 100      
Number undergoing radiotherapy 2 227 123 + 120    
Complications of therapy 3     + 104    
Urinary problems 30 15     15
Sexual dysfunction 317 158     59
Bowel problems 125 62     63
Number of deaths due to prostate cancer 29 36   7  

Trials that screened more often had no effect. This may be because they cause more harm because of more false positive results, and this outweighs the small benefit. In spite of the benefit being limited to ages 55 to 75, in a trial that only tested every three to four years, enthusiasts for screening recommend starting screening from age 40, and testing annually from age 50!

Unfortunately, much of the publicity about screening comes from the United States. Big business drives many of those recommendations. Many American doctors who specialize in issues of the urinary system make more money from selling drug treatment and radiotherapy than from doing their main job of advising and treating patients. Even the PSA test makes large profits for its maker and for medical laboratories. No wonder it is advertised. Moreover, the makers and marketers of adult diapers likely look forward to more prostate treatment, since that brings more business from men who have trouble holding their urine.

Personally, as a male, I have no intention of letting anyone do prostate screening on me until I have problems that need investigation. Dr. Otis Brawley, Chief Medical Officer of the American Cancer Society, is African American (black) and so has a higher risk than a Caucasian (white) man. He also advises against such testing.

All screening tests provide a balance between a small possibility of benefit, and some chance of harm. When the balance is strongly in favour, it is appropriate for doctors to recommend such tests. When the balance is uncertain, they should be more cautious in their recommendations. But even then, it is ultimately you who must decide what is right for you, with doctors helping you to interpret the information.

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FAMILY HEALTH is written with the assistance of
Alberta College of Family Physicians
FAMILY HEALTH is written
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