tag:theconversation.com,2011:/ca/topics/prostate-cancer-957/articlesProstate cancer – The Conversation2024-01-26T13:20:41Ztag:theconversation.com,2011:article/2214852024-01-26T13:20:41Z2024-01-26T13:20:41ZTreatment can do more harm than good for prostate cancer − why active surveillance may be a better option for some<figure><img src="https://images.theconversation.com/files/571270/original/file-20240124-15-qajkje.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2120%2C1414&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A cancer diagnosis is serious, but immediately starting treatment sometimes isn't the best course of action.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/male-professional-doctor-touching-shoulder-royalty-free-image/1412852738">ljubaphoto/E+ via Getty Images</a></span></figcaption></figure><p>Although <a href="https://www.cancer.org/cancer/types/prostate-cancer/about/key-statistics.html">about 1 in 8 men in the U.S.</a> will be diagnosed with prostate cancer during their lifetime, only about 1 in 44 will die from it. Most men diagnosed with prostate cancer die from other causes, especially those with a low-risk prostate cancer that usually grows so slowly it isn’t life-threatening.</p>
<p>However, <a href="https://doi.org/10.1001/jama.2015.6036">until about a decade ago</a>, most men diagnosed with low-risk prostate cancer were immediately treated with surgery or radiation. Although both can cure the cancer, they can also have serious, life-changing complications, including urinary incontinence and erectile dysfunction.</p>
<p>I am a <a href="https://www.researchgate.net/profile/Jinping-Xu-2">family physician and researcher</a> studying how patient-physician relationships and decision-making processes affect prostate cancer screening and treatment. In our recently published research, my colleagues and I found that men are increasingly <a href="https://doi.org/10.1002/cncr.35190">opting against immediate treatment</a>. Instead, they are choosing a more conservative approach known as <a href="https://theconversation.com/prostate-cancer-treatment-is-not-always-the-best-option-a-cancer-researcher-walks-her-father-through-his-diagnosis-206975">active surveillance</a>: keeping a close eye on the cancer and holding off on treatment until there are signs of progression.</p>
<h2>Prostate cancer screening trouble</h2>
<p>Prostate cancer screening is controversial because it often leads to overdiagnosis and overtreatment of cancers that would have otherwise been harmless if left undetected and untreated. </p>
<p>Screening for prostate cancer typically uses a blood test that measures levels of a protein that prostate cells produce called <a href="https://www.cancer.gov/types/prostate/psa-fact-sheet">prostate specific antigen, or PSA</a>. Elevated PSA levels may indicate the presence of prostate cancer, but not all cases are aggressive or life-threatening. And PSA levels can also be elevated for reasons other than prostate cancer, like an enlarged prostate gland due to aging. </p>
<p>Due to widespread PSA screening in the U.S., <a href="https://doi.org/10.1001/jama.2018.3710">over half of prostate cancers</a> detected through screening are low-risk. Concerns about overdiagnosis and overtreatment of low-risk cancers are the main reasons why screening is not recommended unless patients still want to be screened after discussing the pros and cons with their doctor.</p>
<h2>What is active surveillance?</h2>
<p><a href="https://www.cancer.org/cancer/types/prostate-cancer/treating/watchful-waiting.html">Active surveillance</a> is a safe and effective way to manage low-risk prostate cancer by limiting treatments such as surgery or radiation only to cancers that are growing or becoming more aggressive. It involves monitoring tumors through regular checkups and tests.</p>
<p>Active surveillance is different from “<a href="https://www.cancer.org/cancer/types/prostate-cancer/treating/watchful-waiting.html">watchful waiting</a>,” another conservative strategy with a less intense type of follow-up that includes fewer tests and only relieves symptoms. In contrast, active surveillance involves more rigorous monitoring, with more tests to keep a close eye on cancer with the intention to cure if needed.</p>
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<figcaption><span class="caption">Active surveillance has the same survival rates as aggressive treatment for low-risk prostate cancer.</span></figcaption>
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<p>Active surveillance allows patients to delay or avoid invasive treatments and their associated side effects. It aims to balance keeping a close watch on the cancer while avoiding treatments unless they are truly needed.</p>
<p>All leading medical groups <a href="https://doi.org/10.1097/ju.0000000000002854">recommend active surveillance</a> as the preferred approach to caring for men diagnosed with low-risk prostate cancer. However, until recently, the number of patients who opt for active surveillance in the U.S. <a href="https://doi.org/10.1001/jama.2018.19941">has been low</a>, ranging from under 15% in 2010 to about 40% in 2015. The specific reasons why active surveillance is underutilized in the U.S. are not well understood. </p>
<h2>Facilitators and barriers to active surveillance</h2>
<p>What factors influence treatment decisions? To answer this question, my team and I surveyed 1,341 white and 347 Black men with newly diagnosed low-risk prostate cancer from 2014 to 2017. We recruited participants from two cancer registries in metropolitan Detroit and the state of Georgia, regions with large Black populations.</p>
<p>Overall, <a href="https://doi.org/10.1002/cncr.35190">more than half of the men</a> opted for active surveillance. This was much higher than a similar study our team conducted nearly a decade ago, which found that <a href="https://doi.org/10.1007/s40615-015-0109-8">only 10% of men</a> chose active surveillance.</p>
<p>Increased uptake of active surveillance is good news, but it is not where it needs to be. The U.S. is still lagging behind many European countries, such as Sweden, where <a href="https://doi.org/10.1001/jamaoncol.2016.3600">over 80% of patients</a> diagnosed with low-risk prostate cancer select active surveillance. </p>
<p>To figure out what influenced patients to choose active surveillance, we decided to ask them directly. </p>
<p>A urologist’s recommendation had the strongest effect: <a href="https://doi.org/10.1002/cncr.35190">Nearly 85% of patients</a> who chose active surveillance stated that their urologist recommended it. Other factors included a shared patient-physician treatment decision and greater knowledge about prostate cancer. Interestingly, participants living in metro Detroit were more likely to choose active surveillance than those living in Georgia.</p>
<p>Conversely, men were <a href="https://doi.org/10.1002/cncr.35190">less likely to try</a> active surveillance if they had a strong desire to achieve a cure, expected to live longer with treatment or perceived their diagnosis of low-risk cancer was more serious. Almost three-quarters of patients who chose immediate treatment expected to live at least five years longer than they otherwise would without treatment, which is unrealistic and <a href="https://doi.org/10.1016/j.eururo.2020.02.009">not based on existing evidence</a>. </p>
<p>Misperceptions, unrealistic treatment expectations and biases may lead patients to choose unnecessarily aggressive treatment, suffering its harms with no survival benefit and potentially regretting their decision later.</p>
<h2>Racial and geographic differences</h2>
<p>We also found racial and geographic differences in the rate of active surveillance adoption. </p>
<p>On average, <a href="https://doi.org/10.1002/cncr.35190">Black patients had a higher risk</a> of developing and dying from prostate cancer compared with white patients. Additionally, as data supporting the use of active surveillance has been predominantly based on white men, the risks and benefits of active surveillance in Black patients <a href="https://doi.org/10.1016/j.juro.2011.12.082">are more controversial</a>. Indeed, our study found 51% of Black patients chose active surveillance compared with 61% of white patients.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/571274/original/file-20240124-21-yvclop.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Doctor talking with patient and caregiver" src="https://images.theconversation.com/files/571274/original/file-20240124-21-yvclop.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/571274/original/file-20240124-21-yvclop.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/571274/original/file-20240124-21-yvclop.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/571274/original/file-20240124-21-yvclop.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/571274/original/file-20240124-21-yvclop.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/571274/original/file-20240124-21-yvclop.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/571274/original/file-20240124-21-yvclop.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">A urologist’s recommendation can go a long way in encouraging active surveillance.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/compassionate-female-doctor-discusses-medical-royalty-free-image/1401996480">SDI Productions/E+ via Getty Images</a></span>
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<p>Notably, Black men reported receiving fewer active surveillance recommendations from urologists and were less engaged in shared decision-making with their doctors compared with white men. This <a href="https://theconversation.com/doctors-need-to-talk-through-treatment-options-better-for-black-men-with-prostate-cancer-112939">racial difference</a> in active surveillance rates is no longer significant after accounting for urologist recommendations, decision-making style and other factors. </p>
<p>But <a href="https://doi.org/10.1002/cncr.35190">geographic differences</a> persisted: Patients living in Detroit were more likely to undergo active surveillance than those living in Georgia. This likely reflects to some degree the entrenched care patterns of some urologists. Some studies have found that the <a href="https://doi.org/10.1016/j.urology.2020.12.037">longer a urologist was in practice</a>, the less likely they were to recommended active surveillance to their patients.</p>
<h2>Encouraging active surveillance</h2>
<p>Our findings are encouraging in that they show active surveillance has become more acceptable to both patients and urologists over the past decade. However, our results also suggest that greater physician engagement and better patient education can support increased adoption of active surveillance. </p>
<p>For example, when physicians appropriately describe low-risk prostate cancer as small or not aggressive, coupled with a favorable prognosis, this can give patients a sense of relief. Patients in turn <a href="https://doi.org/10.1093/fampra/cmw123">feel more comfortable</a> with undergoing active surveillance.</p>
<p>Conversely, a patient’s misperception of how serious their cancer is may lead to unnecessary treatment. Physicians can reassure patients that active surveillance is a safe and preferred alternative. They can also explain that aggressive treatments <a href="https://doi.org/10.1056/nejmoa1606220">don’t improve survival</a> for most low-risk patients and can cause significant long-term side effects.</p>
<p>More shared treatment decision-making involving patients and their physicians can improve the likelihood of choosing active surveillance compared with patients who make decisions on their own.</p><img src="https://counter.theconversation.com/content/221485/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jinping Xu receives funding from the American Cancer Society and the U.S. Department of Defense. </span></em></p>People with low-risk prostate cancer are more likely to die from something else. Overdiagnosis and overtreatment can lead to life-changing complications.Jinping Xu, Chair of Family Medicine and Public Health Sciences, Wayne State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2069752023-08-08T12:30:04Z2023-08-08T12:30:04ZProstate cancer treatment is not always the best option – a cancer researcher walks her father through his diagnosis<figure><img src="https://images.theconversation.com/files/541121/original/file-20230803-13641-htmsv0.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2147%2C1394&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many patients with less aggressive prostate cancer elect active surveillance instead of treatment.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/daughter-analyzing-test-results-of-old-father-in-royalty-free-image/1394729033">triloks/E+ via Getty Images</a></span></figcaption></figure><p>“Me encontraron càncer en la pròstata,” my father told me. They found cancer in my prostate. </p>
<p>As a <a href="https://scholar.google.com/citations?user=nqSJ0d8AAAAJ&hl=en">cancer researcher</a> who knows very well about the high incidence and decreased survival rates of <a href="https://doi.org/10.1016/j.lana.2022.100295">prostate cancer in the Caribbean</a>, I anguished over these words. Even though I study cancer in my day job, I struggled to take in this news. At the time, all I could muster in response was “What did the doctor say?” </p>
<p>“The urologist wants me to see the radiation oncologist to discuss ‘semillas’ [seeds],” he said. “They are recommending treatment.” </p>
<p>However, I understood from my work that not undergoing treatment was also an option. In some cases, that is the better choice. So I took it upon myself to educate my father on his disease and assist him with the life-changing decisions he would have to make. Our journey can give you a preview of what a cancer diagnosis can be like.</p>
<h2>Prostate cancer diagnosis</h2>
<p>Prostate cancer was not a new topic for my father and me. His battle with his prostate health started 10 years ago with an initial diagnosis of <a href="https://doi.org/10.1016/j.eururo.2008.11.011">benign prostate hyperplasia, or BPH</a>. </p>
<p>The prostate <a href="https://www.niddk.nih.gov/health-information/urologic-diseases/prostate-problems/prostate-enlargement-benign-prostatic-hyperplasia">gets bigger with age</a> for a number of reasons, including changing hormone levels, infection or inflammation. Two of the most frequent symptoms of BPH are difficulty urinating and a sudden, urgent need to urinate, both of which my father experienced. </p>
<p>Although research suggests that the factors that contribute to BPH similarly contribute to prostate cancer, there is no evidence that an enlarged prostate will necessarily <a href="https://doi.org/10.1038/nrurol.2012.192">develop into cancer</a>.</p>
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<figcaption><span class="caption">Prostate cancer diagnoses have risen in the U.S. in recent years.</span></figcaption>
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<p>Upon my father’s initial BPH diagnosis, I asked about his <a href="https://www.cancer.gov/types/prostate/psa-fact-sheet">PSA levels</a>, or the amount of prostate-specific antigens in his blood. PSA is a protein that both normal and cancerous prostate cells produce, and elevated amounts are considered red flags for prostate cancer. When combined with a <a href="https://www.cancer.net/navigating-cancer-care/diagnosing-cancer/tests-and-procedures/digital-rectal-exam-dre">digital rectal exam</a>, a PSA test can allow doctors to more accurately predict a person’s risk of having prostate cancer.</p>
<p>My father said his PSA levels were elevated but that the doctors would begin <a href="https://www.pcf.org/about-prostate-cancer/prostate-cancer-treatment/active-surveillance/">active surveillance</a>, or what he called “watchful waiting,” and monitor his PSA every six months to see if it rose.</p>
<p>After eight years of monitoring his PSA, doctors found my father’s PSA level had doubled. He then got a biopsy that indicated he had intermediate-risk prostate cancer.</p>
<h2>Cancer risk categorization</h2>
<p>After his diagnosis, my father was faced with the decision of how to proceed with treatment. I explained that categorizing how aggressive the cancer is and how far it has spread can help determine the best course of treatment.</p>
<p>Prostate cancer can be <a href="https://www.cancer.org/cancer/prostate-cancer/detection-diagnosis-staging/staging.html">grouped into four stages</a>. Stages 1 and 2, when the tumor is still confined to the prostate, are considered early-stage or intermediate risk. Stages 3 and 4, when the tumor has spread beyond the borders of the prostate, are considered more advanced and high risk.</p>
<p>Some patients with early-stage or intermediate-risk prostate cancer undergo <a href="https://www.cancer.gov/types/prostate/patient/prostate-treatment-pdq#_142">additional treatment</a>, including surgery, radiation or radioactive seed implants called brachytherapy. Patients with late-stage prostate cancer typically undergo hormone therapy along with surgery or radiation, or chemotherapy with or without radiation.</p>
<p>Although I was not surprised by my father’s diagnosis, given his advanced age and his battle with prostate disease over the past decade, I still struggled emotionally. I struggled with our conversations about what “curing” his cancer meant and how to explain his treatment options to him. I wanted to ensure he would have the best outcome and could still live his best life.</p>
<p>Our initial inclination was to undergo <a href="https://www.cancer.gov/publications/dictionaries/cancer-terms/def/active-surveillance">active surveillance</a>. That meant we would monitor his PSA every six months instead of immediately starting treatment. That is appropriate for patients with early-stage and less aggressive tumors.</p>
<h2>Prostate cancer screening problems</h2>
<p>My father was leaning on me to help him decide how to proceed. I felt overwhelming anxiety because I did not want to fail him or my family. Even with all my expertise studying cancer genetics and working with cancer patients, I couldn’t help second-guessing our decisions, and I sometimes questioned our decision not to immediately treat his cancer.</p>
<p>Some people diagnosed with prostate cancer don’t immediately start treatment, because many of the tumors found through PSA testing grow so slowly that they are <a href="https://doi.org/10.7326/0003-4819-158-11-201306040-00008">unlikely to be life-threatening</a>. Detecting these slow-growing tumors is <a href="https://doi.org/10.1038/s41568-019-0142-8">considered overdiagnosis</a>, because the cancer ultimately will not harm the patient during their lifetime. <a href="https://doi.org/10.1016/j.eururo.2013.12.062">Nearly half of all patients</a> with prostate cancer are overdiagnosed, often leading to overtreatment. </p>
<p>Research suggests that many prostate cancer patients undergo unnecessarily aggressive treatments, which are often associated with <a href="https://doi.org/10.1001/jama.2018.3712">significant harms</a>, like urinary and bowel incontinence, sexual impotence and, in some cases, death. Several studies in the U.S. have shown that patients with early-stage prostate cancer have a <a href="https://doi.org/10.1200%2FJCO.2012.44.0586">good prognosis, and the cancer rarely progresses</a> further. With careful observation, most will never need treatment and can be spared the burdens of unnecessary therapy until there are clear signs of progression.</p>
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<figcaption><span class="caption">The U.S. Preventive Services Task Force recommended individualized PSA-based screening in 2018 to avoid overdiagnosis and overtreatment.</span></figcaption>
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<p>Overdiagnosis and overtreatment of prostate cancer led the U.S. Preventive Services Task Force to recommend against PSA-based screening in 2012, with caveats for high-risk groups including African American men and those with a family history of prostate cancer. The recommendation was updated in 2018 to make screening a <a href="https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/prostate-cancer-screening">personal choice after discussion</a> with a clinician. </p>
<p>Those recommendations have resulted in reduced screening and <a href="https://www.nbcnews.com/health/cancer/men-diagnosed-advanced-prostate-cancer-psa-testing-drops-rcna65277">increased prostate cancer diagnoses</a>. Given that Black men are <a href="https://doi.org/10.1002/cncr.34433">more likely to see the cancer progress</a> to aggressive forms of the disease after initial diagnosis, this may worsen existing health disparities.</p>
<p>Developing tests that better identify patients at risk of dying from prostate cancer can decrease overtreatment. In the meantime, educating patients can help them decide if screening is appropriate for them. For underserved and marginalized communities, <a href="https://doi.org/10.4102/safp.v65i1.5621">community outreach</a> can help improve health literacy and enhance awareness and screening.</p>
<p>When I looked through my father’s stack of medical records, I found a beacon of light that eased my apprehension. His doctor had ordered a <a href="https://doi.org/10.1038/modpathol.2017.168">genetic test</a> that estimates how aggressive a tumor may be by measuring the activity of specific genes in cancer cells. An increase in gene activity linked to cancer would indicate that it is likely to grow fast and spread.</p>
<p>The test predicted that my father’s risk of dying from the disease in the next five years was less than 5%. Based on these results, we both understood that he had adequate time to make a decision and seek additional guidance. </p>
<p>My father ultimately decided to continue active surveillance and forgo immediate treatment. </p>
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<a href="https://images.theconversation.com/files/541105/original/file-20230803-23-jtzdmj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Person holding hand of patient lying in hospital bed" src="https://images.theconversation.com/files/541105/original/file-20230803-23-jtzdmj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/541105/original/file-20230803-23-jtzdmj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/541105/original/file-20230803-23-jtzdmj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/541105/original/file-20230803-23-jtzdmj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/541105/original/file-20230803-23-jtzdmj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/541105/original/file-20230803-23-jtzdmj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/541105/original/file-20230803-23-jtzdmj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Because of disparities in access to screening and treatment, African American men are more likely to be diagnosed with advanced prostate cancer.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/son-holding-fathers-hand-at-the-hospital-royalty-free-image/1341484868?phrase=patient+family&adppopup=true">FG Trade/E+ via Getty Images</a></span>
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<h2>Surviving prostate cancer</h2>
<p>I still worry about my father’s diagnosis, because his cancer is at risk for progression. So every six months, I inquire about his PSA levels. His doctors are monitoring his PSA levels as part of his <a href="https://www.cdc.gov/cancer/survivors/life-after-cancer/survivorship-care-plans.htm">survivorship plan</a>, which is a record of information about his cancer diagnosis, treatment history and potential follow-up tests.</p>
<p>My father’s decision to undergo active surveillance was controversial among our friends and family. Many were under the impression that prostate cancer required immediate treatment. Several shared successful treatment stories, sometimes followed by stories of adverse treatment-related side effects.</p>
<p>To date, my father believes that active surveillance was the best decision for him and understands that this may not be the same for someone else. Talk to your doctor to see what the best options are for you or your loved ones.</p><img src="https://counter.theconversation.com/content/206975/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Luisel Ricks-Santi does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Prostate cancer is one of the most common cancers in men. Although watchful waiting is appropriate for low-risk cases, many are diagnosed at an advanced stage because of racial health disparities.Luisel Ricks-Santi, Associate Professor of Pharmacy, University of FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1992492023-05-01T12:09:46Z2023-05-01T12:09:46ZEvery cancer is unique – why different cancers require different treatments, and how evolution drives drug resistance<figure><img src="https://images.theconversation.com/files/522691/original/file-20230424-26-vnh6yd.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2048%2C1560&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Most tumors are made up of many different kinds of cancer cells, as shown in this pancreatic cancer sample from a mouse.</span> <span class="attribution"><a class="source" href="https://visualsonline.cancer.gov/details.cfm?imageid=10654">Ravikanth Maddipati/Abramson Cancer Center at the University of Pennsylvania via National Cancer Institute</a></span></figcaption></figure><p>Cancer is an evolutionary disease. The same forces that turned <a href="https://evolution.berkeley.edu/what-are-evograms/the-origin-of-birds/">dinosaurs into birds</a> turn normal cells into cancer: genetic mutations and traits that confer a survival advantage.</p>
<p><a href="https://www.nature.com/scitable/knowledge/library/evolution-is-change-in-the-inherited-traits-15164254/">Evolution in animals</a> is largely driven by mutations in the DNA of germ cells – the sperm and egg that fuse to form an embryo. These mutations may confer traits that differ from those of the offspring’s parents such as larger paws, sharper teeth or lighter hair color. If the change is beneficial, like a mutation that lightens the hair of a rabbit living in a snowy climate, the animal is better able to survive, mate and pass on its mutated gene to the next generation. Such changes accumulate over millions of years, eventually turning, for example, dinosaurs into bluebirds.</p>
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<figcaption><span class="caption">Evolution is natural selection of particularly advantageous traits over time.</span></figcaption>
</figure>
<p>Cancer arises by these same evolutionary pressures, but at the level of individual cells within a person’s body. Instead of animals fighting for survival in a harsh environment, <a href="https://theconversation.com/microbes-in-your-food-can-help-or-hinder-your-bodys-defenses-against-cancer-how-diet-influences-the-conflict-between-cell-cooperators-and-cheaters-195810">cells compete for space and nutrients</a>. Because different organs are composed of different kinds of cells, cancers arising from different organs differ from one another in appearance and behavior and in how well they respond to treatment.</p>
<p>We are a team of <a href="https://cancer.psu.edu/researchers/individual/-/researcher/5B6500F63D6A38DBE0540010E056499A/monika-joshi-md-mrcp">oncologists</a>, <a href="https://scholar.google.com/citations?user=YEqQHkIAAAAJ&hl=en">pathologists</a> and <a href="https://cancer.psu.edu/researchers/individual/-/researcher/5F6E820FF5C14A2DE0540010E056499A/joshua-warrick-md">translational scientists</a> who work together to study how cancers evolve. We believe that understanding evolution is key to understanding how cancer arises and how to treat it. </p>
<h2>Timing is of the essence</h2>
<p>Human cells are normally in a constant state of death and renewal. Old cells die and are replaced by new ones. These phases of death and renewal are usually orderly, with cells cooperating in a complex process that provides them with proper nutrition and replaces them at a constant rate, maximizing the overall function of the organ they make up. </p>
<p>Mutations disrupt this orderly process. Changes to the cell’s DNA alter the proteins that comprise the cell’s structure and govern its behavior, sometimes in ways that lead it to duplicate itself faster than its neighbors, resist normal death signals and sequester nutrients for itself. </p>
<p>The <a href="https://theconversation.com/anti-cancer-car-t-therapy-reengineers-t-cells-to-kill-tumors-and-researchers-are-expanding-the-limited-types-of-cancer-it-can-target-196471">immune system attacks and kills</a> mutant cells in most cases. However, if one survives and duplicates itself many times over, it can form a tumor made of multiple mutant cells. These tumor cells continue to reproduce and mutate, evolving until the tumor ultimately gains the ability to spread throughout the body.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/523034/original/file-20230426-20-yhvhbj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Microscopy image of precancerous pancreatic tissue in mice" src="https://images.theconversation.com/files/523034/original/file-20230426-20-yhvhbj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/523034/original/file-20230426-20-yhvhbj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=452&fit=crop&dpr=1 600w, https://images.theconversation.com/files/523034/original/file-20230426-20-yhvhbj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=452&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/523034/original/file-20230426-20-yhvhbj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=452&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/523034/original/file-20230426-20-yhvhbj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=568&fit=crop&dpr=1 754w, https://images.theconversation.com/files/523034/original/file-20230426-20-yhvhbj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=568&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/523034/original/file-20230426-20-yhvhbj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=568&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">This microscopy image shows precancerous pancreatic tissue in mice.</span>
<span class="attribution"><a class="source" href="https://directorsblog.nih.gov/2017/06/15/snapshots-of-life-a-van-gogh-moment-for-pancreatic-cancer/">Nathan Krah, University of Utah</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span>
</figcaption>
</figure>
<p>Cancer detected at the earliest stages of this evolution can be treated more effectively than cancer at more advanced stages. This observation underlies the effectiveness of <a href="http://dx.doi.org/10.5888/pcd19.220063">cancer screening programs</a> in reducing cancer rates. </p>
<p>For example, <a href="https://www.cancer.org/cancer/colon-rectal-cancer/about/what-is-colorectal-cancer.html">colon cancer</a> begins as a polyp, a small tumor on the interior surface of the colon that is harmless on its own but may eventually evolve and gain the ability to invade the colon wall and spread throughout the body. Precancerous polyps are easily removed during <a href="https://theconversation.com/colonoscopy-is-still-the-most-recommended-screening-for-colorectal-cancer-despite-conflicting-headlines-and-flawed-interpretations-of-a-new-study-192374">colonoscopy screenings</a>, preventing them from evolving to invasive colon cancer. </p>
<h2>Different cancers require different treatments</h2>
<p>In general, cancers from different organs look distinct from one another and contain different proteins. This leads to variations in how they behave.</p>
<p>Under the microscope, cancer looks like a distorted and disorganized version of the normal tissue from which it arose. Cancer cells tend to contain the same set of proteins as those in healthy organs, and likewise continue to perform many of the same functions. For example, prostate cancer contains large amounts of <a href="https://doi.org/10.5534%2Fwjmh.180040">androgen receptors</a>, proteins that bind to testosterone and drives cells to grow and survive. Androgen receptors both enable normal prostate function and drive growth of prostate cancer.</p>
<p>Tumors arising in a given organ also tend to have mutations in the same set of genes, even among different patients. For example, around <a href="https://doi.org/10.1016/j.cell.2015.05.044">half of patients with melanoma</a>, an aggressive type of skin cancer, have a mutation in the BRAF gene that enhances cell growth and survival. In contrast, BRAF mutations are <a href="https://doi.org/10.1038/nature13385">rare in lung cancer</a>. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/_6CRy1FXVAk?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Pathologists look at tissue samples under a microscope to identify cancer cells.</span></figcaption>
</figure>
<p>Cancers also differ in the number of mutations they contain, and this number is strongly associated with the organ from which they arise. The prevalence of mutations is also influenced by mutations in genes that control DNA repair. For example, <a href="https://doi.org/10.1016/j.cell.2014.09.050">thyroid cancers</a> typically have a low number of mutations while <a href="https://doi.org/10.1038/nature11252">colon cancers</a> have many mutations, a number that is increased dramatically in tumors that have lost genes involved in DNA repair.</p>
<p>Because of these substantial differences in proteins and mutations, tumors from different organs respond differently to treatment. For example, the majority of patients with <a href="https://doi.org/10.1001/jama.1960.03030100059013">testicular cancer</a> can be cured with traditional chemotherapy combined with surgery. However, thyroid cancer and melanoma respond minimally to chemotherapy and require different approaches. Radioactive iodine can only be used to treat <a href="https://www.cancer.org/cancer/thyroid-cancer/treating/radioactive-iodine.html">thyroid cancer</a> because only thyroid cells take up iodine as part of their usual function.</p>
<p>Tumors that contain a large number of mutations often respond well to immunotherapies that help the patient’s immune system attack cancer cells. This is because the immune system sees tumors with more mutations as more foreign and thus mounts a greater response against them. For example, <a href="https://doi.org/10.1056/nejmoa1910836">melanoma</a> and <a href="https://doi.org/10.1056/nejmoa1613683">bladder</a> and <a href="https://doi.org/10.1056/NEJMoa1606774">lung cancers</a> respond well to immunotherapy, particularly those that have lost DNA repair function. In contrast, <a href="https://doi.org/10.1038/d41586-022-02861-y">prostate cancer</a>, which often harbors a low number of mutations, has typically responded poorly to immunotherapies.</p>
<h2>Treatments can drive cancer evolution</h2>
<p>Treatment can also <a href="https://theconversation.com/cancers-are-in-an-evolutionary-battle-with-treatments-evolutionary-game-theory-could-tip-the-advantage-to-medicine-170175">push cancer to evolve further</a>, gaining advantageous mutations that help them survive and resist therapy. </p>
<p>For example, a subset of lung cancers is driven by mutation in a <a href="https://theconversation.com/a-new-way-to-organize-cancer-mutations-could-lead-to-better-treatment-matches-for-patients-168348">gene called EGFR</a>. These are treated with a group of drugs that block the protein the mutant EGFR gene encodes for, slowing the cancer’s growth. Lung cancers treated with these drugs often develop a new EGFR mutation <a href="https://doi.org/10.1073/pnas.0709662105">called T790M</a> that confers resistance to most EGFR inhibitors. However, researchers have <a href="https://doi.org/10.1056/nejmoa1713137">developed another drug</a> that inhibits proteins with T790M and other EGFR mutations more broadly, improving survival for patients with these types of lung cancers.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/h2rR77VsF5c?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Cancer cells can adapt to treatments and become resistant to them.</span></figcaption>
</figure>
<p>Similarly, metastatic prostate cancer is often treated with drugs that block androgen receptors, because it depends on them for growth and survival. Over time, the tumors <a href="https://doi.org/10.1158/0008-5472.can-08-3605">evolve in response to these drugs</a> and develop mutations that change the androgen receptor, massively increase the amount of androgen receptor they produce or, in some cases, completely change their appearance and protein content so they no longer rely on androgen receptors to survive. In these instances, patients require different therapies to overcome resistance. </p>
<h2>Not an easy fight</h2>
<p>The fight against cancer is a fight against evolution, the fundamental process that has driven life on Earth since time immemorial. This is not an easy fight, but medicine has made tremendous progress. </p>
<p>Deaths from cancer in the U.S. have <a href="https://gis.cdc.gov/Cancer/USCS/#/Trends/1,2,1,1,1,value,23">declined since the early 1990s</a>. Much of this is attributable to cancer screening programs and recently developed, more effective drugs. The U.S. Food and Drug Administration approved <a href="https://doi.org/10.1001/jamanetworkopen.2021.38793">332 new drug treatments for cancer</a> between 2009 and 2020. More new drugs are on the way.</p><img src="https://counter.theconversation.com/content/199249/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joshua Warrick receives funding from The National Institutes of Health. </span></em></p><p class="fine-print"><em><span>David DeGraff receives funding from the National Institutes of Health, Congressionally Directed Medical Research Fund/Department of Defense, the American Cancer Society, the Bladder Cancer Advocacy Network, and Bristol Myers Squibb. </span></em></p><p class="fine-print"><em><span>Monika Joshi receives funding from NIH, AstraZeneca, BMS for research related work. She has received funding for research from Pfizer and Eisai in the past. She has received personal fees for advisory board from Seagen, Sanofi and Bayer in the past. </span></em></p>There is no one-size-fits-all approach to treating cancer. Understanding how cancer cells evolve could help researchers develop more effective drugs.Joshua Warrick, Associate Professor of Pathology, Penn StateDavid DeGraff, Associate Professor of Pathology, Penn StateMonika Joshi, Associate Professor of Hematology and Oncology, Penn StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2001752023-03-06T20:03:36Z2023-03-06T20:03:36ZProstate cancer test: is it time to ditch the digital rectal examination?<p>The finger-up-the-bottom examination for prostate cancer has been drawn into question. An international panel of experts recently suggested that so-called digital rectal examination for “active surveillance” should be <a href="https://euoncology.europeanurology.com/article/S2588-9311(23)00002-0/fulltext">replaced by MRI scans</a>.</p>
<p>This news may be celebrated as the overcoming of an intrusive medical examination by the forward march of technology, but what exactly is a digital rectal examination (DRE) and what are the implications of replacing it?</p>
<p>The <a href="https://www.nhs.uk/conditions/rectal-examination/">DRE</a> involves a doctor examining a patient’s rectal wall by inserting a finger into the bottom. This gives doctors access to <a href="https://www.mayoclinic.org/diseases-conditions/prostate-cancer/multimedia/digital-rectal-exam/img-20006434">the prostate gland</a>, helping them find signs of cancer. Before the prostate-specific antigen (PSA) test (from drawn blood) was introduced in 1986, the DRE was the <a href="https://emedicine.medscape.com/article/1948001-overview#:%7E:text=Before%20the%20advent%20of%20serum,relation%20to%20all%20surrounding%20structures.">only method</a> of screening men for prostate cancer.</p>
<p>The DRE can also be used to detect other cancers, such as rectal cancer and anal cancer. It can be used to check for impacted stool in people with constipation, and, under certain circumstances which won’t be discussed further, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3577617/">foreign bodies</a>. </p>
<p>It is also used in women to check for cancer, including the spread of ovarian cancer.</p>
<p>Done correctly, it shouldn’t be too uncomfortable. And privacy and good communication can go a long way in overcoming embarrassment. </p>
<p>All medical students are taught to do it and for generations have been told that when examining patients: “If you don’t put your finger in it, you may put your foot in it.”</p>
<figure class="align-right ">
<img alt="A man having his prostate gland examined." src="https://images.theconversation.com/files/512709/original/file-20230228-26-d4db58.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/512709/original/file-20230228-26-d4db58.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=598&fit=crop&dpr=1 600w, https://images.theconversation.com/files/512709/original/file-20230228-26-d4db58.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=598&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/512709/original/file-20230228-26-d4db58.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=598&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/512709/original/file-20230228-26-d4db58.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=751&fit=crop&dpr=1 754w, https://images.theconversation.com/files/512709/original/file-20230228-26-d4db58.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=751&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/512709/original/file-20230228-26-d4db58.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=751&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A man having his prostate gland examined.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/w/index.php?curid=5581404">National Cancer Institute/Wikimedia</a></span>
</figcaption>
</figure>
<p>The walnut-sized prostate gland sits in the pelvis, surrounding the urethra as it leaves the bladder. Rather conveniently, it lies next to the rectum and is easily felt by the examining finger. </p>
<p>If it is inflamed, as in cases of <a href="https://www.nhs.uk/conditions/prostatitis/">prostatitis</a>, it will be tender. And in <a href="https://www.nhs.uk/conditions/prostate-enlargement/">benign prostate enlargement</a>, which happens in middle age and causes the urinary stream to slow, the prostate gland will feel enlarged. </p>
<p>In cases of cancer of the prostate, the surface may be irregular and the texture firm to the touch. However, it is quite common for <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5985061/">prostate cancer to be missed in the early stages of the disease</a>. </p>
<h2>The gloves are off</h2>
<p>In the UK medical school system, great emphasis is quite rightly placed on learning good clinical skills. Over-reliance on technology is seen as potentially wasteful of scarce resources, and it would seem that patients like to think of their doctors as skilled diagnosticians. But there are times when technology is more accurate at finding disease – especially in its early stages. </p>
<p>Magnetic resonance imaging (MRI) provides detailed pictures of bodily structures. Unlike X-rays and CT scanning, it does not rely on ionising radiation (which is linked to an increased risk of cancer) and is thought to be safe. It is good at picking up early prostate cancer and for “surveillance” (monitoring the disease). </p>
<p>But <a href="https://www.researchgate.net/profile/David-Young-8/publication/353123295_MRICost/links/60e8549cb8c0d5588ce61127/MRICost.pdf">MRI scans are expensive</a> and the machines are bulky, power-hungry and usually confined to hospitals. This limits their use.</p>
<p>There is a blood test, the previously mentioned PSA test, which is used as a marker for diseases of the prostate, but it is not specific for cancer. When used in combination with the DRE, it <a href="https://pubmed.ncbi.nlm.nih.gov/7512659/">helps to detect cases</a>. But PSA levels become elevated after a DRE which makes the timing of testing awkward. It means blood needs to be drawn on a separate visit.</p>
<p>So what is the role of DRE in diagnosing prostate cancer? I believe it still has a place. Prostate cancer spreads easily to the bones, and it is not uncommon for undiagnosed prostate cancer to manifest as back pain when it has spread to the vertebrae. If this is suspected, then positive findings on rectal examination may lead to a more timely diagnosis and fewer delays in getting the correct treatment.</p>
<h2>Gloves on again?</h2>
<p>DRE performs rather better for rectal cancer. If the tumour is in a site accessible to the examiner’s finger, <a href="https://pubmed.ncbi.nlm.nih.gov/17868406/">then up to 76% can be detected</a>.</p>
<p>For constipation, the finding of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8568520/">impacted stool in the rectum</a> can save the expense and radiation exposure of modern investigations, which have done away with X-rays of the abdomen in favour of <a href="https://www.health.harvard.edu/cancer/radiation-risk-from-medical-imaging">radiation-intensive</a> CT scans.</p>
<p>Has the rectal examination had its day? I think not. It’s a cheap examination that yields useful information when used and interpreted correctly.</p><img src="https://counter.theconversation.com/content/200175/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Hughes does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A panel of experts has deemed the digital rectal examination to be inferior to MRI in monitoring prostate cancer in men.Stephen Hughes, Senior Lecturer in Medicine, Anglia Ruskin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2006032023-03-01T12:31:35Z2023-03-01T12:31:35ZAmerican man developed an Irish accent after getting prostate cancer – foreign accent syndrome explained<figure><img src="https://images.theconversation.com/files/512626/original/file-20230228-24-wakqx8.jpg?ixlib=rb-1.1.0&rect=26%2C8%2C5825%2C3755&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/man-talking-alphabet-letters-coming-out-769827094">pathdoc/Shutterstock</a></span></figcaption></figure><p>An American man <a href="https://casereports.bmj.com/content/16/1/e251655">developed an Irish accent</a> following treatment for metastatic prostate cancer. The man was in his 50s and had never been to Ireland. </p>
<p>The accent was described as “uncontrolled”, meaning the man couldn’t stop talking with an Irish brogue, even if he tried. He continued speaking this way until his death.</p>
<p>This is the first time a person has developed “foreign accent syndrome” linked to a prostate cancer diagnosis. And it is <a href="https://casereports.bmj.com/content/16/1/e251655">only the third case</a> of foreign accent syndrome linked to cancer – the others were breast cancer and brain cancer.</p>
<p>Foreign accent syndrome usually happens as a <a href="https://pn.bmj.com/content/16/5/409">result of brain damage</a>, such as from a stroke. Stroke can cause different types of speech and language disorders, but foreign accent syndrome is one of the more unusual ones. </p>
<p>Other causes of the syndrome are changes to the structure of the brain, such as cancer tumours, encephalitis (brain swelling), multiple sclerosis and neurodegenerative disorders such as dementia.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/RbYXXyMb8I0?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Woman on This Morning, ITV, with foreign accent syndrome.</span></figcaption>
</figure>
<p>The condition was first described by <a href="https://en.wikipedia.org/wiki/Pierre_Marie">Pierre Marie</a>, a French neurologist, in 1907. Marie described the case of a man who originally spoke French with a Parisian accent, but after a stroke, he started speaking with a regional French accent from the area of Strasbourg in France. </p>
<p>To date, around 200 cases of foreign accent syndrome have been reported in clinical studies, making it quite a rare speech disorder. Perhaps the best-known case is when <a href="https://www.nme.com/news/music/george-michael-14-1264722">George Michael briefly spoke with a West Country accent</a> when he came out of a coma following a bout of pneumonia in 2011. The singer is from North London.</p>
<p>The condition can be distressing for patients because they lose an important personality characteristic that is expressed by their accent. The impact of this illness was reported in 1947 by the Norwegian neurologist Monrad-Krohn: he <a href="https://doi.org/10.1093/brain/70.4.405">described a Norwegian lady</a> who had suffered a serious head injury in a bombing raid during the second world war. As a result of this damage, she spoke Norwegian with a German foreign accent, and this was quite problematic in postwar Norway.</p>
<p>She was often refused service in shops because people thought she was German. Being identified as a foreigner all the time and being questioned about it can be very distressing. The effect may be so serious that some patients apply unusual methods to find peace of mind. We have heard of a lady with the syndrome saying that she enjoyed staying in hotels because it is very natural to hear a foreign accent in a hotel environment, so it goes unnoticed.</p>
<h2>Psychological causes</h2>
<p>Apart from damage to the central nervous system, foreign accent syndrome can also be caused by psychological factors such as extreme stress. We have identified “<a href="https://www.frontiersin.org/articles/10.3389/fnhum.2016.00168/full">psychogenic foreign accent syndrome</a>” as a separate type of foreign accent syndrome. In 2005, researchers were contacted by a native Dutch speaker who had a heavy and persistent French accent after suffering intense stress as a result of almost being hit by a car. Detailed <a href="https://doi.org/10.1155/2005/989602">neurological investigations</a> did not reveal any brain abnormalities, but psychological tests identified important psychological issues. She only fully returned to her original Dutch accent after ten years.</p>
<p>Another version of this condition is “mixed foreign accent syndrome”. These patients first develop a foreign accent because of brain damage and then try to change their word use to create a more convincing “foreign” personality. This was noticed by researchers at the <a href="https://doi.org/10.1080/02699200400026900">University of Central Florida</a> who saw an American patient who developed a British accent following a stroke and who started using British English words like lift (instead of elevator) and mum (instead of mom). </p>
<p>The patient explained that it was easier for her to allow people to believe that she was from England, rather than trying to explain that her accent was the result of a stroke. Although she insisted that her use of “Briticisms” was not under her conscious control.</p>
<p>Full recovery from the accent change is difficult and often requires intensive speech therapy for a long time. But there have been cases of fairly quick recovery.</p><img src="https://counter.theconversation.com/content/200603/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Johan Verhoeven received funding from the Leverhulme Foundation. </span></em></p><p class="fine-print"><em><span>Stefanie Keulen received funding from Research Council of the Vrije Universiteit Brussel (2013-2017) and the Research Foundation Flanders (2017-2021).</span></em></p>There have only been around 200 reported cases of foreign accent syndrome since it was first reported in 1907.Johan Verhoeven, Professor of Experimental Phonetics, City, University of LondonStefanie Keulen, Assistant Professor/Research Leader, Vrije Universiteit BrusselLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1869982022-08-03T20:05:21Z2022-08-03T20:05:21ZPhysician heal thyself? After 4 years of treatment for stage 4 cancer I just wanted some encouraging words from my oncologist<figure><img src="https://images.theconversation.com/files/477332/original/file-20220803-19-yseiac.jpg?ixlib=rb-1.1.0&rect=128%2C1%2C1074%2C584&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The author in his happy place.</span> <span class="attribution"><span class="source">Photo courtesy UrbnSurf/SurfChimp </span></span></figcaption></figure><p>My oncologist has one of those little motivational prints hanging on his waiting room wall, with the simple statement, “Trust Your Instincts”. One day, bored with the long purgatory of the waiting room, I tweet this news to the world with the observation: “If I trusted my instincts, I’d run screaming from this place and never come back.”</p>
<p>I’m only half-joking. I don’t wish to appear ungrateful for the miracles of modern medicine, without which I very probably would not be alive. Yet the routine of the oncologist’s visit feels deeply dispiriting.</p>
<p>I sit and wait for anywhere up to an hour or more, in an atmosphere thick with dread and stress and anxiety, whiling away the time on my phone or with a trashy magazine, until my name is called. My oncologist takes a cursory glance at my latest blood test results, usually tells me to continue the medication I’m on, writes me a script for another blood test and tells me to come back in four to six weeks. </p>
<p>The final straw comes about four years after my diagnosis of stage four metastatic prostate cancer, as I stand up to leave another perfunctory ten-minute consultation after an hour’s wait. </p>
<p>Something just doesn’t sit right about all this. It’s my life hanging in the balance. I have been through radiation therapy (reasonably tolerable), chemotherapy (seriously debilitating), hormone therapy (made me almost suicidally depressed) and surgery (harrowing but quickly over with).</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/475323/original/file-20220721-12-m6v206.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/475323/original/file-20220721-12-m6v206.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/475323/original/file-20220721-12-m6v206.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=387&fit=crop&dpr=1 600w, https://images.theconversation.com/files/475323/original/file-20220721-12-m6v206.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=387&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/475323/original/file-20220721-12-m6v206.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=387&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/475323/original/file-20220721-12-m6v206.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=487&fit=crop&dpr=1 754w, https://images.theconversation.com/files/475323/original/file-20220721-12-m6v206.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=487&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/475323/original/file-20220721-12-m6v206.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=487&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The author after finishing chemotherapy (on left) in his driver’s licence photo and one year later.</span>
<span class="attribution"><span class="source">Author provided</span></span>
</figcaption>
</figure>
<p>The lack of opportunity for a more wide-ranging conversation about treatment options, how I’m holding up emotionally and strategies to mitigate the life-sapping side effects of treatment just feels wrong.</p>
<p>I walk towards the door, pause, turn and announce, “Oh, one more thing”. </p>
<p>My oncologist does not appear pleased by this development. He has a waiting room full of patients and is already running an hour behind schedule.</p>
<p>“It’s been four years now. I work really hard at this,” I begin tentatively. We’re entering uncharted territory. I’m talking about my feelings and expecting him to respond, a betrayal of our unspoken doctor–patient contract up to this point. I press on regardless.</p>
<p>“I follow a strict diet, exercise and meditate daily, do everything I can to support my health. How do you think I’m going?” </p>
<p>I pose, opening the way for him to offer some soothing words of encouragement. He briefly ponders this unscripted moment, as if I’ve just told a joke he doesn’t quite get. </p>
<p>“About average,” he eventually declares, coolly. “Some of my patients are doing better than you, some worse. You’re about average.”</p>
<p>His response seems designed to ensure I never again have the impertinence to ask such a question, or to attribute any therapeutic powers to my own lifestyle interventions. Even if this was his sincerely held professional view, would it have killed him to say something vaguely positive like, “It’s great that you are being so proactive about supporting your health”? Or a kind-hearted white lie, even if he didn’t actually believe it: “You’re doing great. Keep it up.”</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-kindness-can-make-a-difference-in-cancer-care-90811">How kindness can make a difference in cancer care</a>
</strong>
</em>
</p>
<hr>
<h2>Emotional distance</h2>
<p>I have no reason to doubt my oncologist’s professional expertise and deep knowledge of his chosen field. But I’ve become frustrated by his uninterest in anything I might be doing to support my own health, or any research or suggestions I’ve come across for credible supportive or <a href="https://www.mayoclinic.org/diseases-conditions/cancer/in-depth/adjuvant-therapy/art-20046687">adjuvant</a> treatments, all of which are swiftly dismissed. </p>
<p>More than anything, I’d like a bit more evidence that he cares, which must be hard to deliver when he’s seeing dozens of patients every day at roughly ten-minute intervals, many with conditions far more dire than mine, most of whom he won’t be able to cure. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/477335/original/file-20220803-26-syzxe0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/477335/original/file-20220803-26-syzxe0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/477335/original/file-20220803-26-syzxe0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=651&fit=crop&dpr=1 600w, https://images.theconversation.com/files/477335/original/file-20220803-26-syzxe0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=651&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/477335/original/file-20220803-26-syzxe0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=651&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/477335/original/file-20220803-26-syzxe0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=818&fit=crop&dpr=1 754w, https://images.theconversation.com/files/477335/original/file-20220803-26-syzxe0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=818&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/477335/original/file-20220803-26-syzxe0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=818&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Tim Baker today.</span>
<span class="attribution"><span class="source">Justine Walpole</span></span>
</figcaption>
</figure>
<p>Scottt Morrison <a href="https://www.thesaturdaypaper.com.au/news/politics/2019/10/26/morrison-government-paid-empathy-consultant-190000/15720084008976">reportedly spent almost $200,000</a> on an empathy consultant for his government, but politicians are not the only ones who need a bit of guidance on reading emotional cues. A <a href="https://www.acpjournals.org/doi/abs/10.7326/0003-4819-155-9-201111010-00007">2011 US randomised clinical trial</a> offered oncologists a lecture on good patient communication. Half the group were also offered a tailored CD-ROM presentation to improve their communication styles, recording and critiquing their patient interactions. </p>
<p>The researchers noted the distress and mental health challenges of many cancer patients, observing: </p>
<blockquote>
<p>Oncologists frequently miss opportunities to respond to patient emotion and may instead exhibit behaviours that block feelings and create emotional distance. </p>
</blockquote>
<p>Report author Dr James A. Tulsky observed: </p>
<blockquote>
<p>So often patients aren’t satisfied with the communication they have with their doctor, yet I know physicians care so much about their patients and really want to express that. Physicians may wish to communicate what they are feeling but may not always use the proper words.</p>
</blockquote>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/doctors-are-trained-to-be-kind-and-empathetic-but-a-hidden-curriculum-makes-them-forget-on-the-job-171942">Doctors are trained to be kind and empathetic – but a 'hidden curriculum' makes them forget on the job</a>
</strong>
</em>
</p>
<hr>
<p>The problem here appears to be twofold. Oncologists generally fit a particular psychological profile – disciplined high achievers, able to process and retain vast amounts of highly specialised and technical information and make cool-headed decisions in what are often the most trying circumstances. </p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/477336/original/file-20220803-19-zc7ffh.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/477336/original/file-20220803-19-zc7ffh.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/477336/original/file-20220803-19-zc7ffh.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/477336/original/file-20220803-19-zc7ffh.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/477336/original/file-20220803-19-zc7ffh.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/477336/original/file-20220803-19-zc7ffh.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/477336/original/file-20220803-19-zc7ffh.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/477336/original/file-20220803-19-zc7ffh.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The author’s original bone scan showing cancer in the right femur, or thigh bone, and left rib.</span>
<span class="attribution"><span class="source">Author provided.</span></span>
</figcaption>
</figure>
<p>People with the skill set to perform these demanding functions might not be naturally inclined towards obvious displays of emotion and empathy. And even if they were, it would be almost impossible to be deeply emotionally invested in every patient. Compassion fatigue is real. </p>
<p>But oncologists also suffer from a terrible physical and mental health profile. Numerous studies have shown they have higher incidence of anxiety, depression and suicide than the general population, and are worse at seeking assistance. It’s difficult to offer emotional support when you’re experiencing psychological distress yourself. According to <a href="https://ascopubs.org/doi/10.1200/JCO.2011.39.7380">one US study at the Mayo Clinic</a> up to 35% of oncologists suffer burnout. </p>
<blockquote>
<p>Oncologists are faced with life and death decisions on a daily basis, administer incredibly toxic therapies with narrow therapeutic windows, must keep up with the rapid pace of scientific and treatment advances, and continually walk a fine line between providing palliation and administering treatments that lead to excess toxicity. Personal distress precipitated by such work-related stress may manifest in a variety of ways including depression, anxiety, fatigue, and low mental quality of life.</p>
</blockquote>
<p>A 2019 study found that over <a href="https://ascopubs.org/doi/full/10.1200/EDBK_239087">300 physicians die of suicide in the US every year</a>.</p>
<blockquote>
<p>The stigma of depression runs deep in the helping professions and in medicine in particular. Although burnout in oncology is acknowledged, the other stigmatised mental health aspects of medical practice — depression and suicide — are rarely recorded or talked about.“ </p>
</blockquote>
<p>To compound the problem, oncologists are often reluctant to report mental health issues, considering it a potential blot on their career record. "Physicians have been trained to be perfectionists. They’ve been trained not to ever show any weakness, and they think of mental health issues as weakness,” Anthony L. Back, MD, professor of medical oncology at University of Washington Medical Center, told HemOnc Today, <a href="https://www.healio.com/news/hematology-oncology/20191017/depression-in-oncologists-for-many-a-closely-guarded-secret">an online journal of oncology and hematology</a>.</p>
<p>Another <a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/pon.4382">US study</a> found 30% of oncologists “drink alcohol in a problematic way”, and up to 20% of junior oncologists use hypnotic drugs or sleeping pills.</p>
<p>A 2016 Australian qualitative study on <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0166302">workforce sustainability in oncology</a> paints a similar picture. </p>
<p>Researchers conducted in-depth interviews with 22 medical oncologists at various stages of their careers and concluded: </p>
<blockquote>
<p>There is considerable concern here that increased patient volume and intensification – also shown in other studies – will lead to poorer outcomes for both themselves (e.g. burnout), and their patients in terms of the quality of care and support they expect from their medical oncologists.</p>
</blockquote>
<p>As one early-career cancer specialist put it: </p>
<blockquote>
<p>I think you need to be able to commit that time [to patients] in order to be doing an effective job and if [treatment] becomes a box-ticking exercise … it dehumanises the relationship, which I find a struggle …
When there isn’t time to see everyone and you have to rush them out, I think that really wears down that important part of the patient-doctor dynamic.</p>
</blockquote>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/you-should-care-about-your-doctors-health-because-it-matters-to-yours-78039">You should care about your doctor's health, because it matters to yours</a>
</strong>
</em>
</p>
<hr>
<h2>Ironies</h2>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/476450/original/file-20220728-1332-uzqgfw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/476450/original/file-20220728-1332-uzqgfw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/476450/original/file-20220728-1332-uzqgfw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=915&fit=crop&dpr=1 600w, https://images.theconversation.com/files/476450/original/file-20220728-1332-uzqgfw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=915&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/476450/original/file-20220728-1332-uzqgfw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=915&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/476450/original/file-20220728-1332-uzqgfw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1150&fit=crop&dpr=1 754w, https://images.theconversation.com/files/476450/original/file-20220728-1332-uzqgfw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1150&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/476450/original/file-20220728-1332-uzqgfw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1150&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p>In my own case, I eventually took the advice of that wall mounted print in my oncologist’s office and trusted my instincts.</p>
<p>I sacked my oncologist and found a new one more open to discussing my own lifestyle strategies, showing empathy and concern for my mental struggles and quality of life along with my cancer.</p>
<p>Does it strike anyone else as sadly ironic that one of the most dire health issues of our times is presided over by a profoundly unhealthy physician population? The current model of cancer care serves no one’s best interests, leaving complex patient needs unmet and exacting a cruel toll on clinicians. We are all – patients and doctors alike – casualties in the war on cancer. </p>
<p><em>This is an edited extract from <a href="https://www.penguin.com.au/books/patting-the-shark-9781760898915">Patting The Shark</a> by Tim Baker, published by Penguin Random House Australia, RRP $34.99.</em></p><img src="https://counter.theconversation.com/content/186998/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tim Baker receives funding from Griffith University under a creative writing PhD scholarship</span></em></p>The miracles of modern medicine can be life-saving. Yet as Tim Baker writes, cancer patients yearn for a little empathy from their doctors, as well as scripts.Tim Baker, PhD Candidate, School of Philosophy/author and journalist, Griffith UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1846302022-06-17T12:35:38Z2022-06-17T12:35:38ZDecades of research document the detrimental health effects of BPA – an expert on environmental pollution and maternal health explains what it all means<figure><img src="https://images.theconversation.com/files/468379/original/file-20220613-26-mheqwr.jpg?ixlib=rb-1.1.0&rect=0%2C7%2C5112%2C3395&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The chemical BPA has been shown to leach from food packaging products into our bodies.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/african-woman-drinking-water-royalty-free-image/90306673?adppopup=true">Jacobs Stock Photography Ltd/DigitalVision via Getty Images</a></span></figcaption></figure><p>Whether or not you’ve heard of <a href="https://www.niehs.nih.gov/health/topics/agents/sya-bpa/index.cfm">the chemical bisphenol A, better known as BPA</a>, <a href="https://doi.org/10.1016/j.numecd.2020.01.005">studies show that</a> it’s <a href="https://www.epa.gov/americaschildrenenvironment/biomonitoring-bisphenol-bpa">almost certainly in your body</a>. BPA is used in the manufacturing of products like plastic water bottles, baby bottles, toys and food packaging, including in the lining of cans. </p>
<p>BPA is one <a href="https://www.epa.gov/americaschildrenenvironment/ace-environments-and-contaminants">of many</a> <a href="https://doi.org/10.1016/j.ijgo.2015.09.002">harmful chemicals</a>
<a href="https://doi.org/10.1289/ehp358">in everyday products</a> and <a href="https://www.nrdc.org/sites/default/files/bpa.pdf">a poster child for chemicals in plastics</a>. It is probably best known for its presence in baby bottles due to campaigns by organizations such as <a href="https://saferchemicals.org/2011/03/22/message-in-bpa-baby-bottles-dont-mess-with-moms/">Safer Chemicals, Healthy Families</a> and Breast Cancer Prevention Partners.</p>
<p>An extensive body of research has linked BPA to <a href="https://doi.org/10.1530/REP-17-0734">reproductive health problems</a>, including <a href="https://doi.org/10.1289/EHP3802">endometriosis</a>, <a href="https://doi.org/10.1186/s12958-019-0558-8">infertility</a>, <a href="https://doi.org/10.3390/ijerph18020716">diabetes</a>, <a href="https://doi.org/10.1016/j.jaci.2012.12.1573">asthma</a>, <a href="https://doi.org/10.1177/1559325820916949">obesity</a> <a href="https://neurosciencenews.com/bpa-fetal-development-19902/">and harming</a> <a href="https://doi.org/10.1016/j.envint.2017.12.028">fetal neurodevelopment</a>. </p>
<p>After years of pressure from environmental and public health advocates, the U.S. Food and Drug Administration agreed in June 2022 to <a href="https://www.eenews.net/articles/fda-agrees-to-reassess-bpa-risks/">reevaluate the health risks</a> of BPA. This is significant because a vast body of research <a href="https://doi.org/10.1002/ijgo.14126">has documented that</a> <a href="https://doi.org/10.1016/j.envres.2016.06.008">BPA is leaching from products and packaging</a> into our food and drink and ultimately our bodies.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/SRDUQWJgnn0?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">The game of “chemical Whack-A-Mole” – and how it affects the products you buy.</span></figcaption>
</figure>
<h2>What is BPA?</h2>
<p>BPA is not only used in plastics and food and drink containers but also in pizza boxes, shopping receipts, liners of aluminum cans and much more. Scientists <a href="https://doi.org/10.1371/journal.pone.0120330">have found that BPA</a> <a href="https://doi.org/10.1016/j.jsbmb.2011.05.002">is an endocrine disruptor</a>, which means <a href="https://doi.org/10.1210/endocr/bqaa171">it disrupts hormonal systems</a> that support the body’s functioning and health. </p>
<p>Hormonal disruption is a particular problem during pregnancy and fetal development, when even minor changes can alter the trajectory of developmental processes, including <a href="https://efsa.onlinelibrary.wiley.com/doi/epdf/10.2903/j.efsa.2015.3978">brain and metabolic development</a>. </p>
<p>Over the last two decades, public awareness about the risks led many companies to remove BPA from their products. As a result, studies have shown that BPA levels in people’s bodies <a href="https://doi.org/10.1016/j.envres.2019.05.046">appear to be declining</a> in the U.S. However, a nationwide research team that I helped lead <a href="https://echochildren.org/">as part of a national NIH consortium</a> showed in a <a href="https://doi.org/10.1021/acs.est.1c08942">recent study of pregnant women</a> that the decline in BPA could in part be explained by the fact that BPA replacement chemicals have been on the rise over the last 12 years. And other studies have found that many BPA substitutes are <a href="https://www.science.org/content/article/bpa-substitutes-may-be-just-bad-popular-consumer-plastic">typically just as harmful</a> as the original.</p>
<p>As an environmental health scientist and <a href="https://profiles.ucsf.edu/tracey.woodruff">professor and director</a> of the University of California, San Francisco <a href="https://prhe.ucsf.edu/">Program on Reproductive Health and the Environment</a> who specializes in how toxic chemicals affect pregnancy and child development, I am part of a <a href="https://oehha.ca.gov/proposition-65/developmental-and-reproductive-toxicant-identification-committee-darticmembers">scientific panel</a> that decides if chemicals are reproductive or developmental toxicants for the State of California. In 2015, this committee declared <a href="https://oehha.ca.gov/proposition-65/chemicals/bisphenol-bpa#">BPA a reproductive toxicant</a> because it has been shown to be <a href="https://doi.org/10.1210/en.2016-1887">toxic to ovaries</a>.</p>
<h2>BPA and the FDA</h2>
<p><a href="https://www.fda.gov/food/food-additives-petitions/bisphenol-bpa">BPA was first approved for use</a> in food packaging by the FDA in the 1960s. In 2008, the agency released a draft report concluding that “BPA remains safe in food contact materials.” This assessment was <a href="https://www.latimes.com/archives/la-xpm-2010-jan-16-la-na-fda-bpa16-2010jan16-story.html">met with pushback</a> from many health advocates and environmental health organizations. The FDA claimed BPA to be “safe in food contact materials” as recently as 2018. </p>
<p>Meanwhile, since 2011, Canada and Europe have taken steps to <a href="https://www.chemistryviews.org/details/news/11169386/EU_Wide_Bisphenol_A_Ban_Expected/">ban or limit BPA in children’s products</a>. In 2021, the European Union <a href="https://grist.org/regulation/europe-proposes-dramatic-new-regulation-for-bpa/">proposed “dramatic” decreases</a> <a href="https://www.efsa.europa.eu/en/news/bisphenol-efsa-draft-opinion-proposes-lowering-tolerable-daily-intake">in BPA exposure limits</a> due to a growing body of evidence linking BPA to health harms.</p>
<p>One of the major challenges to limiting harmful chemicals is that regulatory agencies like the FDA try to figure out the levels of exposure that they consider harmful. In the U.S., both the FDA and the Environmental Protection Agency have a long history of underestimating exposures – in some cases because they do not adequately capture “real-world exposures,” or because they fail to fully consider how even small exposures can affect vulnerable populations such as pregnant women and children.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/QuMGc0EswTc?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Surprising research findings on the safety of ‘BPA-free’ products.</span></figcaption>
</figure>
<h2>Latest research</h2>
<p>A large body of research has explored BPA’s <a href="https://doi.org/10.1289/ehp.1307728">effects on reproductive health</a>. These studies have also revealed that many <a href="https://doi.org/10.4093/dmj.2019.0027">BPA substitutes are potentially even worse</a> than BPA and have looked at how these <a href="https://doi.org/10.1080/10408444.2019.1621263">chemicals act in combination</a> with other chemical exposures that can also come from a variety of sources. </p>
<p>And while much attention has been paid to BPA’s effects on pregnancy and child development, there is also significant research on its effects on male reproductive health. It has been linked to <a href="https://www.scientificamerican.com/article/bpa-exposure-linked-to-prostate-cancer/#">prostate cancer</a> and <a href="https://doi.org/10.1016/j.envint.2022.107322">drops in sperm count</a>. </p>
<p>In a study our research team conducted that <a href="https://doi.org/10.1186/s12940-016-0131-2">measured BPA in pregnant women</a>, we asked study participants if they knew about BPA or tried to avoid BPA. Many of our study participants said they knew about it or tried to avoid it, but we found their actions appeared to have no effect on exposure levels. We believe this is, in part, because of BPA’s presence in so many products, some of them known and some unknown that are difficult to control.</p>
<h2>What you can do</h2>
<p>One of the most common questions our staff and clinicians that work with patients are asked is <a href="https://prheucsf.blog/?s=BPA">how to avoid harmful chemicals</a> like BPA and BPA substitutes. A good rule of thumb is to avoid drinking and eating from plastics, microwaving food in plastic and using plastic take-out containers – admittedly easier said than done. Even some paper take-out containers can be lined with BPA or BPA substitutes. </p>
<p>Our <a href="https://doi.org/10.1002/ijgo.14126">recent review of the research</a> found that avoiding plastic containers and packaging, fast and processed foods and canned food and beverages, and instead using alternatives like glass containers and consuming fresh food, can reduce exposures to BPA and other endocrine-disrupting chemicals.</p>
<p>Research has shown that when <a href="https://doi.org/10.1080/15287390903212329">heat comes into contact with plastic</a> – whether water bottles, Tupperware, take-out containers <a href="https://doi.org/10.4315/0362-028x-66.8.1444">or cans</a> – BPA and other chemicals are more likely to leach into the food inside. One should also avoid putting hot food into a food processor or putting plastic containers into the dishwasher. Heat breaks down the plastic, and while the product might appear fine, the chemicals are more likely to migrate into the food or drink – and ultimately, into you.</p>
<p>We also know that when acidic foods like tomatoes are packaged in cans, <a href="https://doi.org/10.1016/j.envres.2016.06.008">they have higher levels of BPA</a> in them. And the amount of time food is stored in plastic or BPA-lined cans can also be a factor in how much the chemicals migrate into the food.</p>
<p>No matter how much people do as individuals, policy change is essential to reducing harmful chemical exposures. A large part of our work at UCSF’s <a href="https://prhe.ucsf.edu/">Program on Reproductive Health and the Environment</a> is to hold regulatory agencies accountable for assessing chemical risks and protecting public health. What we have learned is that it is essential for agencies like the EPA and FDA to use the most up-to-date science and scientific methods to determine risk.</p><img src="https://counter.theconversation.com/content/184630/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tracey Woodruff received funding for BPA research from NIEHS. She receives and has received funding for research on chemical exposures from NIH/NIEHS, USEPA and California EPA.</span></em></p>Due to increasing concerns over the health hazards posed by BPA, the Food and Drug Administration plans to reevaluate the safety of the controversial chemical for use in everyday products.Tracey Woodruff, Professor of Environmental Health, University of California, San FranciscoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1815422022-04-20T16:03:35Z2022-04-20T16:03:35ZProstate cancer linked to bacteria, raising hope of new test and treatment<figure><img src="https://images.theconversation.com/files/458830/original/file-20220420-24727-zxwmcn.jpg?ixlib=rb-1.1.0&rect=0%2C8%2C5991%2C3979&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctors-appointment-physician-shows-patient-shape-1306759789">Shidlovski/Shutterstock</a></span></figcaption></figure><p>Every year, around <a href="https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/prostate-cancer">12,000 men</a> in the UK die from prostate cancer, but many more die with prostate cancer than from it. So knowing whether the disease is going to advance rapidly or not is important for knowing who to treat. </p>
<p>Our latest study, published in <a href="https://euoncology.europeanurology.com/article/S2588-9311(22)00056-6/fulltext">European Urology Oncology</a>, sheds some light on understanding which cancers will progress rapidly and aggressively and which won’t. Part of the answer lies with five types of bacteria. </p>
<p>For some years, we have known that pathogens (bacteria and viruses) can cause cancer. We know, for example, that <em>Helicobacter pylori</em> is associated with <a href="https://doi.org/10.1128/CMR.00012-10">stomach cancer</a> and that the human papillomavirus (HPV) can cause <a href="https://doi.org/10.1016/S2214-109X(16)30143-7">cervical cancer</a>. There is also growing evidence that the bacteria <em>Fusobacterium nucleatum</em> is associated with <a href="https://doi.org/10.1007/s10096-014-2081-3">colorectal cancer</a>.</p>
<p>Here at Norwich Medical School, along with our colleagues at the Norfolk and Norwich University Hospital, the Quadram Institute, and others, we have identified <a href="https://doi.org/10.1016/j.euo.2022.03.006">five types (genera) of bacteria</a> linked to aggressive prostate cancer. These are <em>Anaerococcus</em>, <em>Peptoniphilus</em>, <em>Porphyromonas</em>, <em>Fenollaria</em> and <em>Fusobacterium</em>. We call these the “anaerobic bacteria biomarkers set”, or ABBS.</p>
<p>Bacteria genera are further subdivided into “species”. And here we found four entirely new species of bacteria, three of which are linked to the genera associated with aggressive prostate cancer.</p>
<p>We named two of the new bacteria species after two of the study’s funders: <em>Porphyromonas bobii</em>, after the Bob Champion Cancer Trust and <em>Varibaculum prostatecancerukia</em>, after Prostate Cancer UK.</p>
<p>We examined prostate tissue and urine samples from over 600 men with and without prostate cancer, and when any of the five specific anaerobic bacteria (bacteria that can grow in the absence of oxygen) were detected in patient samples, it was associated with more rapid progression of cancer to aggressive disease. </p>
<p>Indeed, men who had one or more of the bacteria were nearly three times more likely to see their early stage cancer progress to advanced disease, compared with men who had none of the bacteria in their urine or prostate.</p>
<p>We also discovered possible mechanisms of how these bacteria may be linked to cancer, including potential effects on the metabolism of the host human cells.</p>
<h2>Towards a better test</h2>
<p>Current tests for prostate cancer, such as the PSA test and a biopsy, are not always able to predict which cancers will be harmful. We hope that a new test that looks for the ABBS group of bacteria will be better able to detect and screen for potentially aggressive prostate cancer. The new test will be similar to the tests developed to detect <em>Helicobacter pylori</em> associated with stomach cancer or HPV linked to cervical cancer. </p>
<figure class="align-center ">
<img alt="A doctor holding a urine sample jar." src="https://images.theconversation.com/files/458834/original/file-20220420-24684-hm7xcd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/458834/original/file-20220420-24684-hm7xcd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=395&fit=crop&dpr=1 600w, https://images.theconversation.com/files/458834/original/file-20220420-24684-hm7xcd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=395&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/458834/original/file-20220420-24684-hm7xcd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=395&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/458834/original/file-20220420-24684-hm7xcd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=496&fit=crop&dpr=1 754w, https://images.theconversation.com/files/458834/original/file-20220420-24684-hm7xcd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=496&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/458834/original/file-20220420-24684-hm7xcd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=496&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The discovery could lead to new tests for prostate cancer.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-patient-urine-test-cup-physician-1198665856">Tero Vesalainen/Shutterstock</a></span>
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</figure>
<p>Together with our colleagues, we are currently working on this. We are planning to develop robust, rapid tests to detect the five signature bacteria and to investigate new treatment options to remove these bacteria from the urinary tract, bladder and prostate.</p>
<p>Despite our exciting discovery, there are still important questions to answer, such as, are the bacteria causing prostate cancer? If so, how? Also, can we use treatment options to eradicate the bacteria to prevent the development of aggressive disease? Hopefully, we will have answers to these questions soon.</p><img src="https://counter.theconversation.com/content/181542/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rachel Hurst received funding from Prostate Cancer UK and the Bob Champion Cancer Trust. Rachel Hurst is listed as a coinventor on a patent application (UK Patent Application No. 2200682.9) from the University of East Anglia/UEA Enterprises Limited regarding the application of ABBS genera in prostate cancer</span></em></p><p class="fine-print"><em><span>Colin Cooper receives funding from Prostate Cancer UK (research grant ref RIA15-ST2-029, MA-ETNA19-003), the Bob Champion Cancer Trust, and Big C Cancer Charity (ref 16-09R). We are grateful for and acknowledge support from the Masonic Charitable Foundation Successor to the Grand Charity, Movember, the King Family, and the Stephen Hargrave Trust. We also acknowledge funding from Cancer Research UK and Dallaglio Foundation that supported the ICGC project. </span></em></p><p class="fine-print"><em><span>Jeremy Clark receives funding from Prostate Cancer UK. </span></em></p>New research shows five bacteria are associated with an increased risk of aggressive prostate cancer.Rachel Hurst, Senior Research Associate, Norwich Medical School, University of East AngliaColin Cooper, Professor of Cancer Genetics, University of East AngliaJeremy Clark, Research Fellow, Norwich Medical School, University of East AngliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1777872022-02-24T15:24:09Z2022-02-24T15:24:09ZVegetarian, pescatarian or low meat diets may reduce cancer risk – new research<figure><img src="https://images.theconversation.com/files/448337/original/file-20220224-33175-nyx8j2.jpg?ixlib=rb-1.1.0&rect=51%2C0%2C5760%2C3837&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Vegetarians had a 14% lower risk of developing all types of cancer compared to people who regularly eat meat.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/family-lunch-party-home-vegetarian-meal-1662594976">Dejan Dundjerski/ Shutterstock</a></span></figcaption></figure><p>A growing number of people are choosing to eat less meat. There are many reasons people may choose to make this shift, but health is often cited as a popular motive.</p>
<p>A large body of research has shown that plant-based diets can have many health benefits – including lowering the risk of chronic diseases, such as <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002039">type 2 diabetes</a> and <a href="https://www.sciencedirect.com/science/article/pii/S0735109717375216?via%3Dihub">heart disease</a>. Two large studies – <a href="http://www.epic-oxford.org/">EPIC-Oxford</a> and the <a href="https://adventisthealthstudy.org/studies/AHS-2">Adventist Health Study-2</a> – have also suggested vegetarian or pescatarian diets (where the only meat a person eats is fish or seafood) may be linked to a slightly lower overall cancer risk. </p>
<p>Limited research has shown whether these diets could lower risk of developing specific types of cancer. This is what our <a href="https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-022-02256-w">recent study</a> aimed to uncover. We found that eating less meat lower a person’s risk of developing cancer – even the most common types of cancer.</p>
<p>We conducted a large-scale analysis of diet and cancer risk using data from the <a href="https://www.ukbiobank.ac.uk/">UK Biobank</a> study (a database of detailed genetic and health information from nearly 500,000 British people). When participants were recruited between 2006 and 2010, they completed questionnaires about their diet – including how often they ate foods such as meat and fish. We then tracked participants for 11 years using their medical records to understand how their health had changed during this time.</p>
<p>Participants were then categorised into four groups depending on their diet. Around 53% were regular meat-eaters (meaning they ate meat more than five times a week). A further 44% of participants were low meat-eaters (eating meat five or less times a week). Just over 2% were pescatarians, while just under 2% of participants were classified as vegetarians. We included vegans with the vegetarian group as there weren’t enough to study them separately.</p>
<p>Our analyses were also adjusted to ensure other factors that might increase risk of cancer – such as age, sex, smoking, alcohol consumption and sociodemographic status – were taken into account.</p>
<p>Compared with regular meat-eaters, we found the risk of developing any type of cancer was 2% lower for low meat-eaters, 10% lower in pescatarians and 14% lower in vegetarians.</p>
<h2>Specific cancer risk</h2>
<p>We also wanted to know how diet affected risk of developing the three most common types of cancer seen in the UK. </p>
<p>We found that low meat-eaters had a 9% lower risk of colorectal cancer compared with regular meat-eaters. <a href="https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(15)00444-1/fulltext">Previous research</a> has also shown that a higher intake of processed meat in particular is associated with higher colorectal cancer risk. We also found that vegetarians and pescatarians had a lower risk of colorectal cancer, however this was not statistically significant. </p>
<p>We also found that women who ate a vegetarian diet had an 18% lower risk of postmenopausal breast cancer in comparison to regular meat-eaters. However, this association was largely due to the lower average body weight seen in vegetarian women. Previous studies have shown that being overweight or obese after menopause increases <a href="https://www.wcrf.org/dietandcancer/breast-cancer/">risk of breast cancer</a>. No significant associations were observed between postmenopausal breast cancer risk among pescatarians and low meat-eaters.</p>
<figure class="align-center ">
<img alt="A woman holds a bowl of vegetarian foods." src="https://images.theconversation.com/files/448338/original/file-20220224-5831-pbrr7g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/448338/original/file-20220224-5831-pbrr7g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=360&fit=crop&dpr=1 600w, https://images.theconversation.com/files/448338/original/file-20220224-5831-pbrr7g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=360&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/448338/original/file-20220224-5831-pbrr7g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=360&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/448338/original/file-20220224-5831-pbrr7g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=452&fit=crop&dpr=1 754w, https://images.theconversation.com/files/448338/original/file-20220224-5831-pbrr7g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=452&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/448338/original/file-20220224-5831-pbrr7g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=452&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Vegetarian diets were linked with lower breast cancer risk in women.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/healthy-vegetarian-dinner-woman-jeans-warm-1317602774">Foxys Forest Manufacture/ Shutterstock</a></span>
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</figure>
<p>Pescatarians and vegetarians also had a lower risk of prostate cancer (20% and 31% less respectively) in comparison to regular meat-eaters. But it’s not clear whether this is because of diet, or if it’s due to other factors – such as whether or not a person sought cancer screening. </p>
<p>As this was an observational study (meaning we only observed changes to a participant’s health without asking them to make changes to their diet), this means we can’t know for sure if the links we’ve seen are directly caused by diet, or if they’re due to other factors. Although we adjusted the results carefully to take into account other important causes of cancer, such as smoking and alcohol consumption, it’s still possible other factors may still have influenced the results we observed. </p>
<p>Another limitation of our study is that most of the participants <strong>(around 94%)</strong> were white. This means we don’t know whether the same link will be seen in other ethnic groups. It will also be important for future studies to look at a more diverse population, as well as larger numbers of vegetarians, pescatarians and vegans to explore whether this link between lower cancer risk and these types of diets is as strong as we observed. </p>
<p>It’s important to note that simply eliminating meat doesn’t necessarily make your diet healthier. For example, some people who follow a vegetarian or pescatarian diet may still eat low amounts of fruits and vegetables and high amounts of refined and processed foods, which might lead to poor health.</p>
<p>Most evidence showing an association between lower cancer risk and vegetarian or pescatarian diets also seems to suggest that greater consumption of vegetables, fruits and whole grains may explain this lower risk. These groups also don’t consume red and processed meat, which is linked with <a href="https://www.wcrf.org/dietandcancer/meat-fish-and-dairy/">higher colorectal cancer risk</a>. But more evidence will be needed to fully explore the reasons for the results we observed.</p>
<p>The links between red and processed meat and cancer risk are well known – which is why it’s <a href="https://www.wcrf.org/diet-and-cancer/cancer-prevention-recommendations/">widely recommended</a> people aim to limit the amount of these foods they consume as part of their diet. It’s also recommended that people consume a diet rich in whole grains, vegetables, fruits and beans as well as maintain a healthy body weight in order to reduce their risk of cancer.</p><img src="https://counter.theconversation.com/content/177787/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Cody Watling receives funding from Nuffield Department of Population Health Doctoral Scholarship.
The authors would like to thank Dr. Caroline Wood for her writing assistance, language editing, and proofreading of this article.</span></em></p><p class="fine-print"><em><span>Aurora Perez-Cornago receives funding from Cancer Research UK and the World Cancer Research Fund. </span></em></p><p class="fine-print"><em><span>Tim Key receives funding from Cancer Research UK, Wellcome
</span></em></p>Eating less meat was also linked with a lower risk of colorectal, breast, and prostate cancer.Cody Watling, PhD Researcher, Cancer Epidemiology Unit, University of OxfordAurora Perez-Cornago, Senior Nutritional Epidemiologist, University of OxfordTim Key, Professor of Epidemiology, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1660332021-09-08T20:12:17Z2021-09-08T20:12:17Z20 years on, 9/11 responders are still sick and dying<figure><img src="https://images.theconversation.com/files/419188/original/file-20210903-23797-akqghk.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2396%2C1595&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://photos.aap.com.au/search/world%20trade%20center%20attack">Shawn Baldwin/AP/AAP Image</a></span></figcaption></figure><p>Emergency workers and clean-up crew are among 9/11 responders still suffering significant health issues 20 years after the <a href="https://www.history.com/topics/21st-century/9-11-attacks">terrorist attacks</a>.</p>
<p>More than <a href="https://pubmed.ncbi.nlm.nih.gov/18500709/">91,000 workers and volunteers</a> <a href="https://www1.nyc.gov/site/911health/enrollees/rescue-recovery-workers.page">were exposed</a> to a range of hazards during the rescue, recovery and clean-up operations.</p>
<p>By March 2021, some 80,785 of these responders had enrolled in the <a href="https://www.cdc.gov/wtc/">World Trade Center Health Program</a>, which was set up after the attacks to monitor their health and treat them.</p>
<p>Now our <a href="https://www.cambridge.org/core/journals/prehospital-and-disaster-medicine/article/abs/health-trends-among-911-responders-from-20112021-a-review-of-world-trade-center-health-program-statistics/09B87521287B943402782DAADB47E0B9">published research</a>, which is based on examining these health records, shows the range of physical and mental health issues responders still face.</p>
<h2>Breathing problems, cancer, mental illness</h2>
<p>We found 45% of responders in the health program have aerodigestive illness (conditions that affect the airways and upper digestive tract). A total of 16% have cancer and another 16% have mental health illness. Just under 40% of responders with health issues are aged 45-64; 83% are male.</p>
<p>Our analysis shows 3,439 of responders in the health program are now dead — far more than the <a href="https://parade.com/1248604/jessicasager/9-11-facts/">412 first responders who died on the day</a> of the attacks.</p>
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<p>Respiratory and upper digestive tract disorders are the number one cause of death (34%), ahead of cancer (30%) and mental health issues (15%). </p>
<p>Deaths attributed to these three factors, as well as musculoskeletal and acute traumatic injuries, have increased six-fold since the start of 2016. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-the-pain-of-9-11-still-stays-with-a-generation-64725">How the pain of 9/11 still stays with a generation</a>
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<h2>An ongoing battle</h2>
<p>The number of responders enrolling in the health program with emerging health issues rises each year. More than 16,000 responders have enrolled in the past five years. </p>
<p>Cancer is up 185% over the past five years, with leukaemia emerging as particularly common, overtaking colon and bladder cancer in the rankings.</p>
<p>This equates to an increase of 175% in leukaemia cases over a five-year period, which is not surprising. There is a <a href="https://pubmed.ncbi.nlm.nih.gov/32771228/">proven link</a> between benzene exposure and acute myeloid leukaemia. Benzene is found in jet fuel, one of the toxic exposures at the World Trade Center. And acute myeloid leukaemia is one of the main types of leukaemia reported not only by responders, but by <a href="https://www.wtc-illness.com/cancers/leukemia-blood-cancer">residents of lower Manhattan</a>, who also have higher-than-normal rates. </p>
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<p>Prostate cancer is also common, increasing 181% since 2016. Although this fits with the age profile of many of the health program’s participants, some responders are developing an <a href="https://pubmed.ncbi.nlm.nih.gov/31221798/">aggressive, fast-growing form</a> of prostate cancer. </p>
<p>Inhaling the toxic dust at the World Trade Center site may trigger a cascading series of cellular events, increasing the number of inflammatory T-cells (a type of immune cell) in some of the responders. This increased inflammation <a href="https://pubmed.ncbi.nlm.nih.gov/26816843/">may eventually lead to prostate cancer</a>.</p>
<p>There may also be a <a href="https://pubmed.ncbi.nlm.nih.gov/31490535/">significant link between</a> greater exposure at the World Trade Center and a higher risk of long-term cardiovascular disease (disease affecting the heart and blood vessels). Firefighters who responded to the World Trade Center on the morning of the attacks were 44% more likely to develop cardiovascular disease than those who arrived the next day.</p>
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Read more:
<a href="https://theconversation.com/air-pollution-causes-cancer-so-lets-do-something-about-it-19380">Air pollution causes cancer, so let's do something about it </a>
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<h2>The mental health effects</h2>
<p>About <a href="https://pubmed.ncbi.nlm.nih.gov/31625489/">15-20%</a> of responders are estimated to be living with <a href="https://www.beyondblue.org.au/the-facts/anxiety/types-of-anxiety/ptsd">post-traumatic stress disorder</a> (PTSD) symptoms — roughly <a href="https://www.nimh.nih.gov/health/statistics/post-traumatic-stress-disorder-ptsd">four times</a> the rate of the general population. </p>
<p>Despite 20 years having passed, PTSD <a href="https://pubmed.ncbi.nlm.nih.gov/28805168/">is a growing problem</a> for responders. Almost half of all responders <a href="https://pubmed.ncbi.nlm.nih.gov/31776767/">report</a> they need ongoing mental health care for a range of mental health issues including PTSD, anxiety, depression and <a href="https://www.medicalnewstoday.com/articles/325578">survivor guilt</a>.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/9-11-anniversary-a-watershed-for-psychological-response-to-disasters-2975">9/11 anniversary: a watershed for psychological response to disasters</a>
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<p>Researchers <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7364857/">have also found</a> brain scans of some responders indicate the onset of early-stage dementia. This is consistent with <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7364857/">previous work</a> noting cognitive impairment among responders occurs at about twice the rate of people 10-20 years older.</p>
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<h2>COVID-19 and other emerging threats</h2>
<p>Responders’ underlying health conditions, such as cancer and respiratory ailments, have also left them <a href="https://www.usatoday.com/in-depth/news/nation/2021/05/05/covid-risk-911-september-2001-ground-zero-responders-causes-concern/4961779001/">vulnerable to COVID-19</a>. By the end of August 2020, <a href="https://www.newsweek.com/how-many-people-died-911-thousands-perishing-september-11-related-illnesses-1531058">some 1,172 responders</a> had confirmed COVID-19.</p>
<p>Even among responders who have not been infected, the pandemic <a href="https://www.thecity.nyc/2020/9/10/21431746/how-many-9-11-survivors-have-died-of-covid-19">has exacerbated</a> one of the key conditions caused by search and rescue, and recovery after terrorist attacks — PTSD.</p>
<p><a href="https://www.nbcnews.com/news/us-news/covid-19-has-killed-dozens-9-11-first-responders-n1239885">More than 100 responders have died</a> due to complications from the virus, which has also exacerbated other responders’ PTSD symptoms.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1304566412325814274"}"></div></p>
<p>The number of responders with cancers associated with asbestos exposure at the World Trade Center is expected to rise in coming years. This is because mesothelioma (a type of cancer caused by asbestos) usually takes <a href="https://www.canceraustralia.gov.au/cancer-types/mesothelioma-cancer/awareness#:%7E:text=It%20usually%20takes%20a%20very,and%20roofing%2C%20and%20in%20insulation.">20-50 years to develop</a>. </p>
<p>As of 2016, at least 352 responders had been diagnosed with the lung condition <a href="https://www.mayoclinic.org/diseases-conditions/asbestosis/symptoms-causes/syc-20354637">asbestosis</a>, and at least 444 had been diagnosed with another lung condition, <a href="https://www.mayoclinic.org/diseases-conditions/pulmonary-fibrosis/symptoms-causes/syc-20353690">pulmonary fibrosis</a>. Exposure to asbestos and other fibres in the toxic dust <a href="https://www.asbestos.com/world-trade-center/">may have contributed</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-harms-of-asbestos-wont-be-known-for-decades-14845">Health harms of asbestos won't be known for decades </a>
</strong>
</em>
</p>
<hr>
<h2>Lessons learned</h2>
<p>Our research involved analysing data from existing databases. So we cannot make direct links between exposure at the World Trade Center site, length of time there, and the risk of illness. </p>
<p>Differences in age, sex, ethnicity, smoking status and other factors between responders and non-responders should also be considered. </p>
<p>Increased rates of some cancers in some responders may also be associated with <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2764101">heightened surveillance</a> rather than an increase in disease.</p>
<p>Nevertheless, we are now beginning to understand the long-term effects of responding to the 9/11 terrorist attacks. Exposure is still having both a physical and mental health impact and it’s likely responders are still developing illnesses related to their exposures.</p>
<p>Ongoing monitoring of responders’ health remains a priority, especially considering the looming threat of new asbestos-related cancers.</p><img src="https://counter.theconversation.com/content/166033/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>More 9/11 responders died from physical and mental health issues after the terrorist attacks than on the day itself. And survivors are still suffering 20 years later.Erin Smith, Associate Professor in Disaster and Emergency Response, School of Medical and Health Sciences, Edith Cowan UniversityBrigid Larkin, PhD candidate, Edith Cowan UniversityLisa Holmes, Lecturer, Paramedical Science, School of Medical and Health Sciences, Edith Cowan UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1310862020-02-04T13:31:47Z2020-02-04T13:31:47ZCancer deaths decline in US, with advances in prevention, detection and treatment<figure><img src="https://images.theconversation.com/files/313354/original/file-20200203-41476-1hzpaqx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Former President Jimmy Carter pictured at an Atlanta Braves-Toronto Blue Jays game in Atlanta on Sept. 17, 2015, shortly after being treated for melanoma.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Blue-Jays-Braves-Baseball/834e4ba1ad1a4a528b045739bdd89528/30/0">AP Photo/John Bazemore</a></span></figcaption></figure><p>The American Cancer Society recently reported a drop in the overall cancer death rate in the U.S., with an <a href="https://doi.org/10.3322/caac.21590">overall 29% decline</a> in cancer deaths from 1991 to 2017.</p>
<p>This resulted in 2.9 million fewer deaths over this span. </p>
<p>This decline was mainly attributable to progress in the four most common cancers: lung, colorectal, breast and prostate cancer. This included a <a href="https://doi.org/10.3322/caac.21590">record decline of 2.2%</a> in the last year of the report (2016-2017), led by a particularly steep recent drop in lung cancer. And, an article published Jan. 29 in the New England Journal of Medicine found that <a href="https://doi.org/10.1056/NEJMoa1911793">screening current and former heavy smokers</a> with a low-dose CT scan is helping to detect the disease earlier, which is contributing to lower mortality.</p>
<p>I am the <a href="https://www.umassmed.edu/medicine/about-us/department-administration/division-chiefs/">chief of hematology/oncology and medical director</a> of the Cancer Center at the University of Massachusetts Medical School and UMass Memorial Health Care. I take care of patients with cancer, with particular expertise in leukemia and related diseases. The steady decline in cancer deaths is quite encouraging, particularly in lung cancer – which provides a great example of how public health campaigns can change the course of a disease.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/u4bvisvSAu8?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">More women die of lung cancer each year than breast cancer. Low-dose CT screening has been show to make a difference.</span></figcaption>
</figure>
<h2>Lung cancer deaths drop signficantly</h2>
<p>A number of factors have contributed to the reduction in lung cancer deaths, according to the report. Prevention has had a profound impact in reducing lung cancer over the past 25-plus years, primarily through smoking prevention and cessation programs. Smoking among adults is at an all-time low in the U.S., <a href="https://www.cdc.gov/tobacco/data_statistics/fact_sheets/index.htm">at 13.7%</a>. Tobacco is a risk factor for most cancers, and this is particularly true for lung cancer, where smoking is the single greatest cause. </p>
<p>Improved <a href="https://www.cancer.org/latest-news/radon-gas-and-lung-cancer.html">radon detection and mitigation</a> has also helped, as radon exposure represents the <a href="https://www.cancer.org/cancer/cancer-causes/radiation-exposure/radon.html">second most preventable cause</a> of lung cancer. </p>
<p>The advent of <a href="https://doi.org/10.1056/NEJMoa1911793">low-dose computer tomograhy (CT) screening</a> for high-risk patients – current and former heavy smokers – has also played a critical role. Early detection by CT has found lung cancers at a still curable stage, leading to at least a 20% decrease in death rates. </p>
<p>Advances in treatment have accounted for the remainder of progress in lung cancer. The introduction of new drugs, including immunotherapy – which won the <a href="https://www.cancer.org/latest-news/nobel-prize-awarded-to-cancer-immunotherapy-researchers.html">2018 Nobel in Medicine and Physiology</a> for its ability to harness the power of the immune system to kill cancer cells – provides hope for previously untreatable patients. </p>
<p>Despite these successes, lung cancer is still the leading cause of cancer death, with <a href="https://doi.org/10.3322/caac.21590">228,820 new cases and 135,720 deaths</a> predicted for 2020 in the U.S.</p>
<h2>Has progress stalled in the other common cancers?</h2>
<p>The gains in treating <a href="https://doi.org/10.3322/caac.21590">breast, prostate and colorectal cancer</a> have slowed a bit over the past decade. However, to put this in perspective, more deaths are predicted in the U.S. this year from lung cancer than from these other three cancers combined. </p>
<p>Breast, prostate and colorectal cancers have also all benefited from <a href="https://doi.org/10.3322/caac.21590">longstanding screening programs and earlier therapeutic successes</a>, thus setting a higher bar for further improvement compared to lung cancer. </p>
<p>Some of the stalled progress may also reflect rising rates of <a href="https://www.cancer.gov/about-cancer/causes-prevention/risk/obesity/obesity-fact-sheet">obesity</a>, which represents a risk factor for death from each of these cancers.</p>
<p>Last, <a href="https://www.cancerresearch.org/blog/january-2020/cancer-immunotherapy-in-2020-and-beyond">immunotherapy has not yet realized the same gains</a> in these cancers, as in lung and others. </p>
<p>That said, these data extend only up to 2017; so more recent breakthroughs are not yet reflected in the report.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/313357/original/file-20200203-41495-1qo0zzt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/313357/original/file-20200203-41495-1qo0zzt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=358&fit=crop&dpr=1 600w, https://images.theconversation.com/files/313357/original/file-20200203-41495-1qo0zzt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=358&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/313357/original/file-20200203-41495-1qo0zzt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=358&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/313357/original/file-20200203-41495-1qo0zzt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=450&fit=crop&dpr=1 754w, https://images.theconversation.com/files/313357/original/file-20200203-41495-1qo0zzt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=450&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/313357/original/file-20200203-41495-1qo0zzt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=450&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A nurse reaches for blood samples from a patient at the Fred Hutchinson Cancer Center in Seattle that were to be used in CAR-T cell therapy March 21, 2017.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Genetic-Frontiers-Living-Cancer-Drugs/2dde4a1d038640bcb09ef8ea415eaaac/3/0">AP Photo/Elaine Thompson</a></span>
</figcaption>
</figure>
<h2>Dramatic breakthroughs</h2>
<p>Some groundbreaking advances have yielded great successes in selected cancers, with the hope that such treatments may be more broadly applicable. Immunotherapy has proven highly successful <a href="https://doi.org/10.5114/wo.2018.73889">in melanoma</a>. Some may recall the treatment of former <a href="https://www.cancerresearch.org/join-the-cause/cancer-immunotherapy-month/30-facts/20">President Jimmy Carter with pembrolizumab</a>, an immunotherapeutic drug.</p>
<p>This breakthrough, along with the introduction of drugs that specifically target cancer cells to kill them or at least slow their growth, or what scientists call molecular inhibitors, has led to the most pronounced reduction in cancer death rates for melanoma since 2013. These same principles have since been applied with some degree of success to a variety of other cancers. Indeed, this very strategy has been responsible for the some of the <a href="https://doi.org/10.1007/978-3-030-02505-2_3">recent success with lung cancer.</a></p>
<p>Even more impressively, a specific class of drugs called <a href="https://www.cancer.gov/publications/dictionaries/cancer-terms/def/tyrosine-kinase-inhibitor">tyrosine kinase inhibitors</a> dramatically changed the course of chronic myeloid leukemia (CML) over the past two decades. These drugs shut off a key signaling pathway that the CML cells depend upon for their growth and survival, thus converting CML from a universally fatal disease to one with which most patients will live a near normal lifespan. Targeted inhibitors have also revolutionized the treatment and prognosis of chronic lymphocytic leukemia and a number of other blood cancers. </p>
<p>In addition, the past quarter century has seen tremendous advances in the treatment of pediatric acute lymphocytic leukemia – the most common form of childhood cancer, with cure rates now <a href="https://www.cancer.org/cancer/leukemia-in-children/detection-diagnosis-staging/survival-rates.html">approaching 90%</a>. Another type of leukemia, <a href="https://www.lls.org/sites/default/files/National/USA/Pdf/Publications/APL_FactSheet_10_15FINAL.pdf">acute promyelocytic leukemia</a>, also now has cure rates in excess of 80%, thanks to the introduction of <a href="https://doi.org/10.1038/sj.onc.1204763">all-trans retinoic acid</a> (an active form of Vitamin A) and the subsequent addition of arsenic over the past several decades. </p>
<p>One of the most exciting advances has been another form of immunotherapy – <a href="https://doi.org/10.3390/jcm8020207">chimeric antigen receptor (CAR) T cells</a> – which have produced extraordinary results in some of the most challenging blood cancers. These genetically re-engineered immune cells are reprogrammed to seek out and destroy cancer cells with remarkable efficiency. This highly promising therapy is now FDA-approved for some types of leukemia and lymphoma; it is also now being explored in many other types of cancer, including solid tumors.</p>
<h2>Putting it all in perspective</h2>
<p>These remarkable advances in cancer prevention, detection and treatment provide great hope. In fact, it is important to note that the ACS data extend only through 2017, so many recent breakthroughs are not yet reflected in the report. </p>
<p>That said, there is still much work to be done, and funding support for ongoing research remains critical.</p>
<p>Improved participation in, increased availability of, and better design of clinical trials are also desperately needed to advance the field. Cancer is rapidly approaching heart disease as the number one cause of death in the U.S., and we have made far too little progress with many types of cancer. </p>
<p>Furthermore, access to state-of-the-art, much less cutting-edge, cancer care remains limited, with significant racial and socioeconomic disparities. This is particularly true for <a href="https://doi.org/%2010.1200/JGO.18.00200">developing countries</a>, where many tests and therapies are prohibitively expensive and are simply not available to most citizens. </p>
<p>Armed with a better understanding of cancer and a host of new strategies to treat it, we oncologists are quite optimistic that the next decade will yield impressive results in the battle against cancer. We must ensure not only continued progress, but also that these advances reach all patients, in an effort to stamp out cancer across the world.</p>
<p>[ <em>Like what you’ve read? Want more?</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=likethis">Sign up for The Conversation’s daily newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/131086/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jonathan M. Gerber does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Cancer mortality has dropped in the US, due largely to lower smoking rates, as well as early detection and better treatments. These advances often do not extend to people in developing nations.Jonathan M. Gerber, Chief of Hematology/Oncology, Medical Director of the Cancer Center, and Eleanor Eustis Farrington Chair in Cancer Research, UMass Chan Medical SchoolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1277912020-01-26T19:06:45Z2020-01-26T19:06:45Z29,000 cancers overdiagnosed in Australia in a single year<figure><img src="https://images.theconversation.com/files/307817/original/file-20191218-11924-3kufdx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Men are 17% more likely to be diagnosed with cancer than they were 30 years ago.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/frustrated-older-mature-retired-man-feeling-1185179038">fizkes/Shutterstock</a></span></figcaption></figure><p>Almost one in four cancers detected in men were overdiagnosed in 2012, according to our new research, published today in the <a href="https://www.mja.com.au/">Medical Journal of Australia</a>. </p>
<p>In the same year, we found that approximately one in five cancers in women were overdiagnosed. </p>
<p>Overdiagnosis is when a person is diagnosed with a “harmless” cancer that either never grows or grows very slowly. These cancers are sometimes called low or ultra-low-risk cancers and wouldn’t have spread or caused any problems even if left untreated.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/is-it-time-to-remove-the-cancer-label-from-low-risk-conditions-101331">Is it time to remove the cancer label from low-risk conditions?</a>
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<p>This level of overdiagnosis means Australian men are 17% more likely to be diagnosed with cancer in their lifetime than they were 30 years ago, while women are 10% more likely. </p>
<p>Cancer overdiagnosis can result in people having unnecessary treatments, such as surgery, radiotherapy and hormone therapy. Being diagnosed with cancer and having cancer treatments can cause physical, psychological and financial harms.</p>
<h2>How many cancers were overdiagnosed?</h2>
<p>In 2012, 77,000 cancers were diagnosed among Australian men. We estimated that 24% of these (or 18,000 in total) were overdiagnosed, including:</p>
<ul>
<li>8,600 prostate cancers</li>
<li>8,300 melanomas</li>
<li>860 kidney cancers</li>
<li>500 thyroid cancers.</li>
</ul>
<p>Some 55,000 cancers were diagnosed in women; 18% of them (11,000) were overdiagnosed. This includes:</p>
<ul>
<li>4,000 breast cancers</li>
<li>5,600 melanomas</li>
<li>850 thyroid cancers</li>
<li>660 kidney cancers.</li>
</ul>
<p>These calculations are based on changes since 1982 in the lifetime risk of cancers, after adjusting for other causes of death and changing risk factors.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/307819/original/file-20191218-11896-18a61i1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/307819/original/file-20191218-11896-18a61i1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/307819/original/file-20191218-11896-18a61i1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/307819/original/file-20191218-11896-18a61i1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/307819/original/file-20191218-11896-18a61i1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/307819/original/file-20191218-11896-18a61i1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/307819/original/file-20191218-11896-18a61i1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Mammograms sometimes detect cancers that wouldn’t grow, spread, or cause the woman any harm.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/woman-40s-about-undergoing-mammography-test-195635468">GagliardiPhotography/Shutterstock</a></span>
</figcaption>
</figure>
<p>Because they are more common, prostate and breast cancer and melanoma accounted for the greatest number of overdiagnosed cancers, even though larger percentages of thyroid cancers were overdiagnosed. </p>
<p>In women, for example, 73% of thyroid cancers were overdiagnosed, while 22% of breast cancers were overdiagnosed.</p>
<p>The harms to patients come from the unnecessary surgery, and other treatments, as well as the anxiety and expenses. </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/29042396">Three in four patients with thyroid “cancers” that are overdiagnosed</a>, for example, will almost all have their thyroid completely removed, risk complications, and have to take replacement thyroid medication for the rest of their life. </p>
<p>In addition, there are substantial costs to the health system, and delays in necessary surgery. </p>
<p>Some “good news” is that overdiagnosis appears to be largely confined to the five main cancers mentioned above. </p>
<h2>What causes cancer overdiagnosis?</h2>
<p>The cause of overdiagnosis differs for each cancer. </p>
<p>For prostate cancer, the cause is the quest for early detection of prostate cancer using the prostate specific antigen (PSA) blood test. A downside of PSA testing is the risk of detecting large numbers of low-risk prostate cancers which may be overtreated. </p>
<p>For breast cancer, the cause is also early detection, through mammography screening which can detect low-risk cancers. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/five-warning-signs-of-overdiagnosis-110895">Five warning signs of overdiagnosis</a>
</strong>
</em>
</p>
<hr>
<p>Likewise, detection of low-risk melanoma accounted for most of the melanoma overdiagnosis we observed. Early detection activities again are the likely cause, with many times more skin biopsies being done today than 30 years ago.</p>
<p>Overdiagnosis of kidney and thyroid cancer is due largely to “incidentalomas” – abnormalities found incidentally on imaging done for other reasons – or through over-investigation of mild thyroid problems.</p>
<h2>What can we do about it?</h2>
<p>Some level of overdiagnosis is unavoidable in a modern health-care system committed to screening to reduce the disease and death burden from cancer.</p>
<p>We want to maximise the timely detection of high-risk cancers that allows the best chance of cure through early surgery and other treatments. </p>
<p>But this is still possible while taking measures to prevent overdiagnosis and overtreatment of low-risk cancers that are better left undetected. </p>
<p>Take South Korea, for example. Following the introduction of a screening program for thyroid cancer, the country saw a <a href="https://www.nejm.org/doi/full/10.1056/NEJMc1507622?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed">15-fold increase</a> in small, low-risk thyroid cancers. Then it cut back on early detection. This led to a major drop in thyroid cancer rates without any change in death rates. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/307820/original/file-20191218-11914-1lyx0sn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/307820/original/file-20191218-11914-1lyx0sn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=408&fit=crop&dpr=1 600w, https://images.theconversation.com/files/307820/original/file-20191218-11914-1lyx0sn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=408&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/307820/original/file-20191218-11914-1lyx0sn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=408&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/307820/original/file-20191218-11914-1lyx0sn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=512&fit=crop&dpr=1 754w, https://images.theconversation.com/files/307820/original/file-20191218-11914-1lyx0sn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=512&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/307820/original/file-20191218-11914-1lyx0sn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=512&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Rates of PSA testing are comparatively high in Australia.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/man-laboratory-during-blood-research-68481031">ariadna de raadt/Shutterstock</a></span>
</figcaption>
</figure>
<p>Rates of PSA testing in Australia are <a href="https://cancercouncil.com.au/wp-content/uploads/2015/03/World-Journal-of-Urology_2015_Prostate_mortality-AUS.pdf">among the highest in the world</a>. Countries where there is less PSA testing, such as the <a href="https://researchonline.nd.edu.au/cgi/viewcontent.cgi?article=1777&context=med_article">United Kingdom</a>, detect less low-risk prostate cancer, and therefore have less overtreatment.</p>
<p>Rather than simply accepting PSA testing, a wiser strategy is to <a href="https://www.bmj.com/content/362/bmj.k3581.full">make an informed decision whether to go ahead with it or not</a>. Tools to help you choose are available <a href="http://psatesting.org.au/info/?utm_source=pcfa&utm_medium=redirect&utm_campaign=pcam19">here</a> and <a href="https://www.racgp.org.au/download/Documents/Guidelines/prostate-cancer-screening-infosheetpdf.pdf">here</a>.</p>
<p>A <a href="https://ses.library.usyd.edu.au/bitstream/2123/16658/1/2017%20updated%20breast%20screening%20DA%20%28Hersch%20et%20al%29.pdf">decision aid</a> is also available for Australian women to consider whether to go ahead with mammogram screening or not.</p>
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Read more:
<a href="https://theconversation.com/three-questions-to-ask-about-calls-to-widen-breast-cancer-screening-82894">Three questions to ask about calls to widen breast cancer screening</a>
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<p>Trials to wind back treatment of low-risk prostate cancer have resulted in <a href="https://www.nice.org.uk/guidance/ng131/chapter/Recommendations#localised-and-locally-advanced-prostate-cancer">clinical practice guidelines</a> which recommend men with low-risk prostate cancer be offered active surveillance as an alternative to immediate surgery or radiation therapy. </p>
<p>Trials to evaluate less treatment for low-risk breast cancer are now under way and should help wind back breast cancer overtreatment one day.</p>
<p>New screening tests that identify clinically important cancers, while leaving slow- and never-growing cancers undetected, are the holy grail. But they could be some time coming. </p>
<p>In the meantime, health services need to be vigilant in <a href="https://annals.org/aim/fullarticle/2724039/recognizing-potential-overdiagnosis-high-sensitivity-cardiac-troponin-assays-example">monitoring new areas of overdiagnosis</a>, particularly when investing in new technologies with potential to further increase overdiagnosis.</p><img src="https://counter.theconversation.com/content/127791/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alexandra Barratt receives funding from NHMRC. She is a lead investigator on Wiser Healthcare, an NHMRC funded research collaboration to reduce overdiagnosis and overtreatment. </span></em></p><p class="fine-print"><em><span>Katy Bell receives funding from NHMRC. She is Chief Investigator on an Investigator Grant "Using early detection tests to benefit health without causing harm" and a member of the Wiser Healthcare research collaboration that aims to reduce overdiagnosis and overtreatment. </span></em></p><p class="fine-print"><em><span>Paul Glasziou receives funding from an NHMRC program grant on overdiagnosis and overtreatment.</span></em></p><p class="fine-print"><em><span>Mark Jones and Thanya Pathirana do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>New research estimates 24% of cancers in men that were detected in 2012 were overdiagnosed, meaning they never would have caused harm if left untreated.Alexandra Barratt, Professor of Public Health, University of SydneyKaty Bell, Associate in Clinical Epidemiology in the School of Public Health, University of SydneyMark Jones, Associate Professor, Biostatistician, Institute for Evidence-Based Healthcare, Bond UniversityPaul Glasziou, Professor of Medicine, Bond UniversityThanya Pathirana, Senior Lecturer, School of Medicine, Griffith UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1263882019-11-06T14:09:39Z2019-11-06T14:09:39ZMen over 40 with faulty BRCA2 gene should be tested annually for prostate cancer<figure><img src="https://images.theconversation.com/files/300439/original/file-20191106-12459-1yhi63j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1087772366?src=1b78c88f-14ee-497f-95d1-8d3d68655d95-1-3&size=medium_jpg">Jarun Ontakrai/Shutterstock</a></span></figcaption></figure><p>Scientists at The Institute of Cancer Research, London, are calling for <a href="https://www.icr.ac.uk/news-archive/men-over-40-with-brca2-gene-fault-should-get-regular-psa-screening">annual blood tests</a> to detect aggressive prostate cancer in men who have a fault in the BRCA2 gene. After researching the effectiveness of the test, Ros Eeles, who led the study, said: “Our research shows very clearly that men with the BRCA2 gene fault are at increased risk of aggressive prostate cancer and that regular PSA testing could go some way to improving early diagnosis and treatment.”</p>
<p>The <a href="https://www.nhs.uk/conditions/prostate-cancer/should-i-have-psa-test/">PSA test</a> is done using a small amount of blood to detect raised levels of prostate specific antigen (PSA). Yet, despite its relatively low cost and ease of administering, it is not offered for routine screening in many countries, <a href="https://www.cancerresearchuk.org/about-cancer/prostate-cancer/getting-diagnosed/screening">including the UK</a>. This is because a significant proportion of those testing positive have no disease (a false-positive result), slow-growing cancer that doesn’t need treatment, or positive results caused by a relatively benign condition, such as a urinary tract infection.</p>
<p>Detecting prostate cancer early is important and saves lives. But many of those identified by the PSA test as having elevated levels of the antigen could potentially undergo painful treatment with significant life-altering side effects, which were unnecessary. Also, up to <a href="https://www.nhs.uk/conditions/prostate-cancer/psa-testing/">15% of men with prostate cancer have normal PSA levels</a> (a false-negative result), meaning that many men would receive unwarranted reassurance from this test.</p>
<p>Guidelines in most countries, therefore, note that the <a href="https://www.sciencedirect.com/science/article/abs/pii/S0025712517300329?via%3Dihub">possible benefits of testing are outweighed by the potential harms</a> of over-diagnosis and over-treatment, making it unsuitable for screening everyone.</p>
<h2>Faulty BRCA2 gene</h2>
<p>Men with faults in their BRCA2 gene are, however, <a href="https://bmccancer.biomedcentral.com/articles/10.1186/s12885-018-4098-y">five times more likely</a> to be diagnosed with prostate cancer and at a younger age. More worryingly, this high-risk group is also <a href="https://www.icr.ac.uk/news-archive/men-over-40-with-brca2-gene-fault-should-get-regular-psa-screening">twice as likely to have a more serious</a>, potentially life-threatening, form of prostate cancer.</p>
<p>Faults in the BRCA2 gene are more commonly linked to breast cancer, and this is where it gets its name (BReast CAncer). The gene itself was originally identified by looking at families and <a href="https://www.cancer.gov/about-cancer/causes-prevention/genetics/brca-fact-sheet#are-mutations-in-brca1-and-brca2-more-common-in-certain-racialethnic-populations-than-others">groups that showed higher than normal levels of breast cancer</a>. This includes people of Icelandic, Scottish, Northern Irish, Quebecois and Ashkenazi Jewish origin, where specific faults in the BRCA2 gene are seen.</p>
<p>In both these families and groups, researchers also identified higher than normal levels of <a href="https://www.macmillan.org.uk/information-and-support/diagnosing/causes-and-risk-factors/genetic-testing-and-counselling/men-brca2.html">male breast cancer</a> (yes, men can also get breast cancer), prostate, pancreatic and other cancers.</p>
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Read more:
<a href="https://theconversation.com/why-men-dont-need-to-be-screened-for-breast-cancer-but-should-still-do-regular-checks-49775">Why men don't need to be screened for breast cancer, but should still do regular checks</a>
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<p>I became involved in BRCA2 research, shortly after its discovery in 1994. The discovery of this gene was a major advance in the fight against cancer and we came up with a wide range of possible ways that faults in the gene could lead to cancer. </p>
<p>Painstaking research over many years has shown that the gene plays a vital role in repairing breaks in our DNA. When this process does not occur properly, because of problems in the gene, the result is a build up of mutations. This can then lead to cancer-causing changes in the rest of the DNA, and this is why screening for early signs, including the PSA test, becomes more important.</p>
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<h2>Who should be seeking advice on genetic testing?</h2>
<p>While certain groups have a greater chance of carrying particular faults in their DNA, any family could be passing down dangerous changes in BRCA2 through the generations. So if several members of your family have had breast cancer, prostate cancer and particularly if there are any incidences of male breast cancer, it may be worth speaking to your doctor. You may then be sent to have your <a href="https://www.nhs.uk/conditions/predictive-genetic-tests-cancer/">DNA tested for faults in the gene</a>.</p>
<p>In people with an identified risk, there is a range of options available. Not all changes in BRCA2 carry the same risk and carriers must weigh up the risks against the invasiveness of any preventative measures. In some cases, increased vigilance and more regular checks, such as the PSA test, may be enough.</p>
<p>More extreme precautionary measures are also sometimes taken. For example, actress Angelina Jolie opted to have a <a href="https://theconversation.com/angelina-jolie-pitts-surgery-is-just-one-option-for-women-at-risk-of-cancer-39329">double mastectomy</a> and removal of her ovaries and fallopian tubes after finding that a fault in her BRCA1 gene (another major gene involved in cancers) put her at a greater risk of breast and ovarian cancer. Her mother had breast cancer and both her mother and grandmother <a href="https://www.nytimes.com/2015/03/24/opinion/angelina-jolie-pitt-diary-of-a-surgery.html">died from ovarian cancer</a>.</p>
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Read more:
<a href="https://theconversation.com/angelina-jolie-pitts-surgery-is-just-one-option-for-women-at-risk-of-cancer-39329">Angelina Jolie Pitt's surgery is just one option for women at risk of cancer</a>
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<p>The PSA test is <a href="https://www.bmj.com/content/362/bmj.k3581">not reliable enough to be used as a general screening method</a> for prostate cancer. But in men with BRCA2 faults, it does appear to play a vital role and calls for its annual use for these men need to be carefully considered. There is also a need to identify those people carrying this faulty gene. At the same time, finding better ways of screening for prostate cancer remains the goal of many researchers.</p><img src="https://counter.theconversation.com/content/126388/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Porter does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Men with faults in their BRCA2 gene are at higher risk of aggressive prostate cancer.Michael Porter, Lecturer in Molecular Genetics, University of Central LancashireLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1258182019-10-29T05:10:27Z2019-10-29T05:10:27ZDoes eating dairy foods increase your risk of prostate cancer?<figure><img src="https://images.theconversation.com/files/298863/original/file-20191028-113987-1aoxwt0.jpg?ixlib=rb-1.1.0&rect=16%2C25%2C5590%2C3707&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">If you're a male who enjoys dairy, there's no reason to stop having it.</span> <span class="attribution"><span class="source">From shutterstock.com</span></span></figcaption></figure><p><em><a href="https://theconversation.com/au/topics/research-check-25155">Research Checks</a> interrogate newly published studies and how they’re reported in the media. The analysis is undertaken by one or more academics not involved with the study, and reviewed by another, to make sure it’s accurate.</em></p>
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<p>Recent headlines <a href="https://thenewdaily.com.au/life/wellbeing/2019/10/22/dairy-prostate-cancer-risk/">have warned</a> a diet high in dairy foods may increase men’s risk of prostate cancer. </p>
<p>The news is based on a <a href="https://jaoa.org/article.aspx?articleid=2753613">recent review</a> published in the Journal of the American Osteopathic Association which claimed to find eating high quantities of plant-based foods may be associated with a decreased risk of prostate cancer, while eating high quantities of dairy products may be associated with an increased risk.</p>
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<p>But if you’re a man, before you forego the enjoyment and known nutritional benefits of milk, cheese and yoghurt, let’s take a closer look at the findings.</p>
<h2>What the study did</h2>
<p>This study was a review, which means the researchers collated the findings of a number of existing studies to reach their conclusions.</p>
<p>They looked at 47 studies which they claim constitute a comprehensive review of all available data from 2006-2017. These studies examined prostate cancer risk and its association with a wide variety of foods including vegetables, fruits, legumes, grains, meat (red, white and processed), milk, cheese, butter, yoghurt, total diary, calcium (in foods and supplements), eggs, fish and fats.</p>
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Read more:
<a href="https://theconversation.com/six-foods-that-increase-or-decrease-your-risk-of-cancer-28270">Six foods that increase or decrease your risk of cancer</a>
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<p>Some studies followed groups of men initially free of prostate cancer over time to see if they developed the disease (these are called cohort studies). Others compared health habits of men with and without prostate cancer (called case-control studies). Some studies recorded the incidence of prostate cancer in the group while others concentrated on the progression of the cancer.</p>
<p>For every potential risk factor, the reviewers marked studies as showing no effect, or an increased or decreased risk of prostate cancer. The results varied significantly for all the foods examined.</p>
<p>For cohort studies (considered more reliable than case-control studies), three studies for vegan diets and one for legumes recorded decreased risk of prostate cancer. For vegetarian diets and vegetables, some reported decreased risk and some recorded no effect. Fruits, grains, white meat and fish appeared to have no effect either way.</p>
<p>An increased risk was reported for eggs and processed meats (one study each), red meat (one out of six studies), fats (two out of five), total dairy (seven out of 14), milk (six out of 15), cheese (one out of six), butter (one out of three), calcium (three out of four from diet and two out of three from supplements) and fats (two out of five).</p>
<p>Notably, some very large cohort studies included in the review showed no association for milk or other dairy products. And most case-control studies, though admittedly less reliable, showed no association.</p>
<p>The authors also omitted other studies published within the review period which showed <a href="https://www.ncbi.nlm.nih.gov/pubmed/18584476">no significant association</a> between dairy and prostate cancer.</p>
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<img alt="" src="https://images.theconversation.com/files/298879/original/file-20191028-113972-11es3ym.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/298879/original/file-20191028-113972-11es3ym.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/298879/original/file-20191028-113972-11es3ym.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/298879/original/file-20191028-113972-11es3ym.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/298879/original/file-20191028-113972-11es3ym.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/298879/original/file-20191028-113972-11es3ym.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/298879/original/file-20191028-113972-11es3ym.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A person’s weight likely has more influence on their risk of developing prostate cancer than whether or not they eat dairy.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
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<p>So the inconsistency in results across the studies reviewed – including large cohort studies – amount to very limited evidence dairy products are linked to prostate cancer.</p>
<h2>Could it be vitamin D?</h2>
<p>In earlier research, a link between milk and prostate cancer has been attributed to a high calcium intake, possibly changing the production of a particular form of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5858034/">vitamin D</a> within the body. </p>
<p>Vitamin D is an important regulator of cell growth and proliferation, so scientists believed it may lead to prostate cancer cells growing unchecked. But the evidence on this is limited, and the review adds little to this hypothesis. </p>
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Read more:
<a href="https://theconversation.com/psa-testing-for-prostate-cancer-is-only-worth-it-for-some-93284">PSA testing for prostate cancer is only worth it for some</a>
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<p>Perhaps the review’s most surprising omission is mention of the <a href="https://www.wcrf.org/dietandcancer/prostate-cancer">World Cancer Research Fund (WCRF) Continuous Update Project report on prostate cancer</a>. This rigorous global analysis of the scientific literature identified much stronger risk factors that should be considered as possible confounding factors.</p>
<p>For example, the evidence is rated as “strong” that being overweight or obese, and being tall (separate to weight), are associated with increased risk of prostate cancer. The exact reasons for this are not fully understood but could be especially significant in Australia where <a href="https://www.aihw.gov.au/reports/overweight-obesity/overweight-and-obesity-an-interactive-insight/contents/what-is-overweight-and-obesity">74% of men are overweight or obese</a>.</p>
<p>A <a href="https://www.ncbi.nlm.nih.gov/pubmed/31552571">new Australian study</a> found a higher body mass index was a risk factor for aggressive prostate cancer.</p>
<p>For dairy products and diets high in calcium, according to the WCRF, the evidence remains “limited”.</p>
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Read more:
<a href="https://theconversation.com/why-full-fat-milk-is-now-ok-if-youre-healthy-but-reduced-fat-dairy-is-still-best-if-youre-not-122184">Why full-fat milk is now OK if you're healthy, but reduced-fat dairy is still best if you're not</a>
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<h2>It’s about the whole diet</h2>
<p>It’s not wise to judge any diet by a single food group or nutrient. A healthy diet overall should be the goal.</p>
<p>That being said, milk, cheese and yoghurt are included in <a href="https://www.eatforhealth.gov.au/guidelines">Australia’s Dietary Guidelines</a> because of evidence linking them with a lower risk of heart disease, type 2 diabetes, bowel cancer and excess weight. These dairy products are also sources of protein, calcium, iodine, several of the B complex vitamins, and zinc.</p>
<p>Evidence about dairy products and prostate cancer remains uncertain. So before fussing about whether to skip milk, cheese and yoghurt, men who wish to reduce their risk of prostate cancer would be better advised to lose any excess weight. <strong>– Rosemary Stanton</strong></p>
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<h2>Blind peer review</h2>
<p>I agree with the author of this Research Check who highlights there is a high degree of variability in the results of the studies examined in this review. </p>
<p>While the authors searched three journal databases, most comprehensive reviews search up to eight databases. Further, the authors did not undertake any assessment of the methodological quality of the studies they looked at. So the results should be interpreted with caution. </p>
<p>Although the authors concluded higher amounts of plant foods may be protective against prostate cancer, the figure presented within the paper indicates more studies reported no effect compared to a decreased risk, so how they came to that conclusion in unclear. For total dairy they present a figure showing there were as many studies suggesting no effect or lower risk as there were showing higher risk. </p>
<p>Importantly, they did not conduct any meta-analyses, where data are mathematically pooled to generate and overall effect across all studies.</p>
<p>As the reviewer points out, many other important sources of high quality data have not been included and there are a number of recent higher quality systematic reviews that could be consulted on this topic. <strong>- Clare Collins</strong></p><img src="https://counter.theconversation.com/content/125818/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Clare Collins is affiliated with the Priority Research Centre for Physical Activity and Nutrition, the University of Newcastle, NSW. She is an NHMRC Senior Research and Gladys M Brawn Research Fellow. She has received research grants from NHMRC, ARC, Hunter Medical Research Institute, Meat and Livestock Australia, Diabetes Australia, Heart Foundation, Bill and Melinda Gates Foundation, nib foundation, Rijk Zwaan Australia and Greater Charitable Foundation. She has consulted to SHINE Australia, Novo Nordisk, Quality Bakers, the Sax Institute and the ABC. She was a team member conducting systematic reviews to inform the Australian Dietary Guidelines update and the Heart Foundation evidence reviews on meat and dietary patterns.</span></em></p><p class="fine-print"><em><span>Rosemary Stanton does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A recent study reported a high consumption of dairy products was associated with an increased risk of prostate cancer. But breaking down the results shows there’s no reason for men to give up dairy.Rosemary Stanton, Visiting Fellow, School of Medical Sciences, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1205332019-07-26T13:42:44Z2019-07-26T13:42:44ZProton therapy for prostate cancer: does the evidence support the hype?<figure><img src="https://images.theconversation.com/files/285169/original/file-20190722-11318-18l12af.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A proton beam therapy clinic in Poland. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/501085849?src=yhoowEePCn9xQjTfcd7YIw-1-1&studio=1&size=medium_jpg">dominika zarzycka/Shutterstock</a></span></figcaption></figure><p>High energy proton beam therapy, an advanced form of radiotherapy, made its debut in the UK in 2018. Both the NHS and private clinics began offering this treatment in the same year, but they treated very different patient groups. While the NHS used the therapy to treat <a href="https://www.bbc.co.uk/news/health-46958785">childhood cancer</a>, private clinics began treating men with prostate cancer. </p>
<p>The situation is similar in other countries. Prostate cancer patients are the most common referral for proton beam therapy in the US and internationally make up the majority treated at many proton centres.</p>
<p>But who sees the greatest benefit from proton beam therapy? And do these benefits justify the substantial cost of treatment (often <a href="https://www.ft.com/content/7a15b9e2-3d89-11e8-b7e0-52972418fec4">tens of thousands of pounds</a>)? While there is strong evidence for the benefits of <a href="https://www.nature.com/articles/nrclinonc.2013.79">proton therapy in children</a>, it is much less clear in <a href="https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(14)70304-3/fulltext">prostate and other adult cancers</a>. </p>
<p>This apparent disconnect between evidence and practice underpins fundamental disagreements about the standard of evidence needed for new treatments and the role of patient choice in healthcare. </p>
<h2>Why protons?</h2>
<p>Proton therapy is an <a href="https://theconversation.com/explainer-what-is-proton-therapy-16100">alternative form of radiotherapy</a>, which is conventionally delivered using X-rays. Both approaches aim beams of radiation at the tumour, killing cancerous cells when they interact with and damage the patient’s DNA. But radiation can also damage healthy tissues and organs that surround the tumour, which can cause side effects.</p>
<p>Modern X-ray radiotherapy minimises these side effects using clever delivery methods. The tumour is treated from many different directions, meaning it can be given a greater dose of radiation while reducing the dose to healthy tissues, and hence the damage. But X-ray radiotherapy still delivers a significant radiation dose to healthy tissues that lie in front of and behind the tumour.</p>
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<p>Unlike photons (used in X-ray radiotherapy) which travel right through the body, protons only travel a certain distance through the body before stopping. By carefully tuning this range, it is possible for proton therapy to deliver almost no dose beyond the tumour. This greatly reduces the total dose to healthy tissues. </p>
<p>It is argued that this advantage makes proton therapy a better approach than conventional radiotherapy. And this is true for some cancers. For example, reducing the total dose received by children significantly reduces risks of delays in their development and additional cancers later in life. Protons can also make it easier to deliver precise treatments to tumours close to sensitive organs, such as the spinal cord or optic nerve.</p>
<h2>Protons in prostate cancer</h2>
<p>In prostate cancer (and many other adult cancers) the benefits are less clear. A big advantage of protons is the reduction in the total dose delivered to the patient. However, the main side effects associated with this are much less significant in adults: delays in development are not a factor, and the risk of additional cancers are <a href="https://www.bmj.com/content/352/bmj.i851">much lower</a> as they typically take decades to develop. </p>
<p>Instead, the main side effects are seen in organs close to the prostate that also receive a high dose, such as the bladder and rectum. A high dose must be delivered to a region that includes the prostate and some additional healthy tissues, to make sure the disease is treated fully. The extra margin allows for the variation that occurs during treatment, such as differences in the way the patient lies down, to make sure the cancer gets a full dose each day. As these patient variations are independent of the radiation type, protons and X-rays typically deliver similar high doses to these healthy tissues. </p>
<p>Despite this, proton therapy has been widely adopted because it is argued the physical benefits are clear, even if small, and will become apparent with time as more people reach the five and ten-year survival mark. But the results of studies investigating the effects of proton therapy on prostate cancer are mixed. While protons have been shown to an effective treatment for prostate cancer, <a href="https://www.nature.com/articles/s41391-019-0140-7">no consistent advantage</a> has been seen for either long-term survival or quality of life.</p>
<p>One challenge in measuring the benefit of proton therapy for prostate cancer is that conventional radiotherapy is already highly effective. In early stage prostate cancer (stages one to three), <a href="https://www.sciencedirect.com/science/article/pii/S1470204516301024">nine out of ten men</a> treated with X-rays are expected to remain cancer free after five years. They also have relatively low rates of long-term side effects compared with many other cancers. As a result, there is a limited scope for proton therapy to improve outcomes, precisely because the outcomes are already so good. As technology develops this will further reduce side effects and improve rates of remission in conventional radiotherapy, and mean it is increasingly hard to show a benefit from proton beam therapy.</p>
<p>As a result, the NHS and the <a href="https://www.astro.org/Daily-Practice/Reimbursement/Model-Policies/Proton-Beam-Therapy-for-Prostate-Cancer-Position-S">American Society for Radiation Oncology</a> (ASTRO) do not recommend proton therapy for prostate cancer except as part of a clinical trial. Several of these large international trials are underway, but it will be about a decade before we have conclusive results. Even then, it is expected that protons will represent, at best, an evolution rather than a revolution in prostate cancer radiotherapy.</p>
<p>This has not prevented a demand for prostate proton therapy driving a dramatic expansion in the <a href="https://www.bmj.com/content/344/bmj.e2488">number of proton therapy centres internationally</a>. In part this is because prostate cancer is one of the most common types of cancer. Treatment for common cancers may actually serve to support the availability of proton therapy for other, rarer cancers. But, it is crucial the benefits for every individual are properly considered. </p>
<p>It is difficult for dry position statements from organisations like the NHS and ASTRO to compete with the dramatic promises proton therapy clinics make. But a balanced discussion of the benefits and costs of all types of radiotherapy is essential to ensure patients have all the evidence to hand before they part with their cash.</p><img src="https://counter.theconversation.com/content/120533/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen McMahon has received funding from the European Commission.</span></em></p>Private proton centres are targeting patients who might not see the most benefit from expensive treatments.Stephen McMahon, Queen's University Research Fellow, Queen's University BelfastLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1097152019-04-25T21:51:12Z2019-04-25T21:51:12ZPain during sex? Incontinence or constipation? You might benefit from pelvic floor physiotherapy<figure><img src="https://images.theconversation.com/files/267435/original/file-20190403-177175-4fvomr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Up to 20 per cent of women have pain during sexual intercourse and up to 40 per cent have issues with bladder control. Physiotherapy can help. </span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>“How did I not know this was a pelvic floor issue? Why didn’t my doctor send me here sooner? Do you have other patients with problems like mine?”</p>
<p>As a physiotherapist, I hear these questions again and again, from people of all ages and genders, who are <a href="https://www.penguinrandomhouse.com/books/558308/a-headache-in-the-pelvis-by-david-wise-phd-and-rodney-anderson-md/9781524762049/">struggling with issues related to the urinary system, sexual function and the lower digestive tract</a>.</p>
<p>Adrian is one example. A 35 year-old active cyclist and successful professional, he has a nagging pain in the private parts that just won’t go away. It is interfering with his sporting activities and ruining his sex life. Pressure from the bicycle seat, the ambitious effort to cycle 100 kilometres in record time, and the stress from a crazy week at work have all resulted in pelvic floor muscle tension and <a href="https://uroweb.org/wp-content/uploads/26-Chronic-Pelvic-Pain_LR.pdf">chronic pelvic pain</a>. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/267437/original/file-20190403-177187-9x2544.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/267437/original/file-20190403-177187-9x2544.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/267437/original/file-20190403-177187-9x2544.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/267437/original/file-20190403-177187-9x2544.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/267437/original/file-20190403-177187-9x2544.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/267437/original/file-20190403-177187-9x2544.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/267437/original/file-20190403-177187-9x2544.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Pelvic floor issues can affect anyone.</span>
<span class="attribution"><span class="source">(Unsplash/JaneSundried)</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<p>Then there’s Lisa, a 63 year-old woman who is ready to become involved in a new relationship. In her search for a companion, she explores online dating and begins to realize that sex may be involved sooner than later. She worries that she may not be ready, physically, not having had sex for quite a few years, and wonders what she could do to improve her vaginal comfort and physical confidence.</p>
<p>These patients, and many others, did not know that a physiotherapist could help them. In my role as a clinician and as course co-ordinator for pelvic floor rehabilitation at <a href="https://www.mcgill.ca/spot/">McGill University’s School of Physical and Occupational Therapy</a>, I see a huge lack of awareness of the impact that physiotherapy can have on the lives of people suffering these very personal conditions.</p>
<p>From pain during sexual intercourse to urinary incontinence after surgery for prostate cancer, to anal incontinence after pregnancy, physiotherapy can help. </p>
<h2>Pain during sexual intercourse</h2>
<p>Up to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5969816/">20 per cent of women have pain during sexual intercourse</a>. This is a surprising statistic, especially when it predominantly includes active women in their twenties and thirties, who may believe that there is something psychologically wrong with them when all of the gynaecological tests come up negative.</p>
<p>Vestibulodynia, an invisible hypersensitivity at the entrance to the vagina, is considered the<a href="https://www.ncbi.nlm.nih.gov/pubmed/27080365"> most common cause of sexual pain in pre-menopausal women</a>. It can be treated in physiotherapy.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/270823/original/file-20190424-121228-12czx1a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/270823/original/file-20190424-121228-12czx1a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/270823/original/file-20190424-121228-12czx1a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/270823/original/file-20190424-121228-12czx1a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/270823/original/file-20190424-121228-12czx1a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/270823/original/file-20190424-121228-12czx1a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/270823/original/file-20190424-121228-12czx1a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Pelvic floor physiotherapy can help reduce pain during sexual intercourse.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>The pelvic floor muscles span the private area under the pelvis. They are responsible not only for helping to control the passage of urine, stool and gas, but also for allowing comfort and pleasure during sex.</p>
<p>These muscles also support the pelvic organs and help with balance and stability. It is important to be able to contract and to relax these muscles. <a href="https://www.sciencedirect.com/topics/medicine-and-dentistry/kegel-exercise">Pelvic floor exercises train the muscles for the desired result</a>, and are sometimes referred to as “targeted” Kegels.</p>
<p>In <a href="https://www.issm.info/sexual-health-qa/what-is-pelvic-floor-physical-therapy/">pelvic floor physiotherapy</a>, patients learn exercises, and they may receive manual treatments, biofeedback and/or electrical stimulation. Biofeedback displays pelvic floor activity on a computer screen, making it easier to contract and relax muscles that are usually hidden from view. Electrical stimulation causes a pain-free muscle contraction, with the goal of improving the ability to contract and relax naturally. </p>
<p>Research supports the <a href="https://doi.org/10.1002/14651858.CD005654.pub4">use of physiotherapy</a> in the treatment of <a href="https://doi.org/10.1002/14651858.CD003882.pub4">a variety of pelvic disorders</a>. A team approach is ideal, and, depending upon the condition, may involve collaboration with general practitioners, urologists, gynaecologists, sex therapists and others.</p>
<h2>Prostate, pregnancy and potty</h2>
<p>After surgery for prostate cancer, <a href="https://dx.doi.org/10.5152%2Ftud.2014.222014">up to 40 per cent of men experience problems with urinary incontinence</a>. Pelvic floor physiotherapy teaches men different strategies to control leakage. Men can even consult prior to surgery, in order to prepare. </p>
<p>Women experience an array of pelvic floor issues during and after pregnancy. It is important to mention that <a href="https://www.ncbi.nlm.nih.gov/pubmed/9740521">many women who have had a third or fourth degree tear during delivery will experience issues with anal incontinence later in life</a>.</p>
<p>Some countries systematically refer these patients for preventative physiotherapy and some centres in Canada are now beginning to follow suit.</p>
<p>More than 40 per cent of women also have issues with bladder control. Patients with <a href="https://doi.org/10.1016/j.jogc.2017.11.027">stress urinary incontinence</a> and those with <a href="https://www.cua.org/themes/web/assets/files/4586_v3.pdf">an overactive bladder</a> can experience significant improvement in physiotherapy.</p>
<p>Physiotherapy is considered first-line intervention for <a href="http://www.canadiancontinence.ca/EN/">both types of incontinence</a> by the <a href="https://www.ics.org">International Continence Society</a>, the <a href="https://www.cua.org/en">Canadian Urological Association</a> and the <a href="https://uroweb.org">European Association of Urology</a>. </p>
<p>Constipation is another issue that may be caused by the inability to relax the muscles of the pelvic floor and anal sphincter at the appropriate time. Physiotherapists can work to improve “defecation dynamics” and provide suggestions for lifestyle changes. </p>
<p>In children, constipation may lead to soiling or overflow incontinence. Children may also be seen for <a href="https://doi.org/10.1053/j.gastro.2016.02.015">urinary disorders</a>.</p>
<h2>A co-ordinated physiotherapy plan</h2>
<p>The internet has been instrumental in enabling patients to learn about embarrassing or taboo subjects in the privacy of their own homes, and has led many to seek out physiotherapy as a viable treatment option for pelvic conditions.</p>
<p>Patients consulting for pelvic floor issues learn how the bladder functions, how the pelvic floor muscles can be involved in constipation, what causes the muscles to be such culprits in pelvic pain and how new brain research supports a bio-psycho-social approach for the management of their problems. They find an ally in the physiotherapist, who supports them and directs them towards the improvement of their condition.</p>
<p>A step-by-step coordinated physiotherapy plan is a key element in the interdisciplinary management of patients with disorders related to the pelvic floor.</p><img src="https://counter.theconversation.com/content/109715/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Claudia Brown is co-owner of Physiothérapie Uro-Santé, a company aimed at teaching physiotherapists about pelvic floor physiotherapy. She is also owner and manager of a group of private physiotherapy clinics that offer pelvic floor physiotherapy in the Montreal area, including Physiothérapie Polyclinique Cabrini and La Clinique de Physiothérapie Concorde.</span></em></p>A step-by- step coordinated physiotherapy plan is key for patients with disorders related to the pelvic floor.Claudia Brown, Assistant Professor, School of Physical and Occupational Therapy, McGill UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1146212019-04-08T20:08:13Z2019-04-08T20:08:13ZWe need new rules for defining who is sick. Step 1: remove vested interests<figure><img src="https://images.theconversation.com/files/267270/original/file-20190403-177167-yakeo4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Early detection of disease can be a double-edged sword.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Did you know the definition of high blood pressure (hypertension) in the United States was recently greatly expanded? Overnight, tens of millions of people were reclassified, leaving one in every two adults with a diagnosis of hypertension. </p>
<p>The move has been welcomed by some but also <a href="https://www.aafp.org/afp/2018/0315/p372.html">widely criticised</a>, amid concerns the expanded definition may <a href="https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2678449">bring more harm than good</a> to many people, from unnecessary illness labels and unneeded drugs. </p>
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Read more:
<a href="https://theconversation.com/new-blood-pressure-guidelines-may-make-millions-anxious-that-theyre-at-risk-of-heart-disease-93349">New blood pressure guidelines may make millions anxious that they're at risk of heart disease</a>
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<p>What about the condition called “chronic kidney disease” (CKD), diagnosed by measuring blood levels to estimate kidney function? Because it does not account for normal ageing, the current definition labels up to one in two older people as having “CKD”. </p>
<p>But many of those labelled will never have any kidney symptoms, chronic or otherwise, and there’s been <a href="https://www.bmj.com/content/347/bmj.f4298">repeated criticism within the medical literature</a>. That broad new “disease” was created at a conference sponsored by a major drug company.</p>
<p>Then there are the recent changes to the definition of gestational diabetes which mean up to one in five pregnant women may now be diagnosed. But it’s <a href="https://theconversation.com/are-you-at-risk-of-being-diagnosed-with-gestational-diabetes-it-depends-on-where-you-live-112515">unclear</a> whether many among the newly diagnosed mothers or their babies might benefit from this expansion.</p>
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Read more:
<a href="https://theconversation.com/are-you-at-risk-of-being-diagnosed-with-gestational-diabetes-it-depends-on-where-you-live-112515">Are you at risk of being diagnosed with gestational diabetes? It depends on where you live</a>
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<p>It’s time for a major change in how disease definitions and diagnostic thresholds are set. We outline a proposal for how this might happen today in the the journal <a href="https://ebm.bmj.com/content/early/2019/04/11/bmjebm-2018-111148">BMJ Evidence-Based Medicine</a>.</p>
<h2>The growing problem of overdiagnosis</h2>
<p>In all these examples, the danger is that more and more people may be <a href="https://theconversation.com/preventing-over-diagnosis-how-to-stop-harming-the-healthy-8569">overdiagnosed</a>. Overdiagnosis means receiving a diagnosis that isn’t likely to benefit you. </p>
<p>Supporters of expanded definitions often have the best of intentions, motivated to diagnose ever milder problems and treat them early. </p>
<p>But early detection can be a double-edged sword. For some people you prevent serious illness, for others you overdiagnose and overtreat things that would never progress and never cause any harm.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/267271/original/file-20190403-177190-9hf5od.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/267271/original/file-20190403-177190-9hf5od.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/267271/original/file-20190403-177190-9hf5od.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/267271/original/file-20190403-177190-9hf5od.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/267271/original/file-20190403-177190-9hf5od.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/267271/original/file-20190403-177190-9hf5od.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/267271/original/file-20190403-177190-9hf5od.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Panels of experts determining where to set the threshold for the diagnosis of disease often have financial ties to drug companies.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/619218203?size=huge_jpg">Africa Studio/Shutterstock</a></span>
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<p>One common example is prostate cancer. Researchers <a href="https://bmjopen.bmj.com/content/9/3/e022457">recently estimated</a> that more than 40% of all the prostate cancer now detected via testing healthy men in Australia may be overdiagnosed. In other words, those cancers would not have caused symptoms or problems during a man’s lifetime, yet they are now being detected and treated with surgery or radiotherapy, often with major complications.</p>
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Read more:
<a href="https://theconversation.com/most-people-want-to-know-risk-of-overdiagnosis-but-arent-told-41889">Most people want to know risk of overdiagnosis, but aren't told</a>
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<p>Our <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001500">research</a> a few years ago studied the panels of experts who actually change the definitions of common conditions, such as high blood pressure or depression. </p>
<p>We found three things. When they made changes, panels tended to expand definitions and label more previously healthy people as ill. </p>
<p>Second, they did not appear to rigorously investigate the downsides of that expansion. </p>
<p>And third, these panels tended to be dominated by doctors with multiple financial ties to drug companies with interests in expanding markets.</p>
<h2>A proposal to reform how diseases are defined</h2>
<p>Today, an international group of influential researchers and family doctors launch a proposal to address this problem of expanding disease definitions. Published in <a href="https://ebm.bmj.com/content/early/2019/04/11/bmjebm-2018-111148">BMJ Evidence-Based Medicine</a>, our proposal is for new processes and new people.</p>
<p>The new processes include rigorously examining evidence for benefits and potential harms, before reclassifying millions of healthy people as diseased. This was proposed in a world-first <a href="https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2626860">checklist</a> for groups seeking to change definitions, developed by the Guidelines International Network.</p>
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Read more:
<a href="https://theconversation.com/five-commonly-over-diagnosed-conditions-and-what-we-can-do-about-them-82319">Five commonly over-diagnosed conditions and what we can do about them</a>
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<p>As for new people, today’s article suggests new multidisciplinary panels led by generalists, rather than specialists. It calls for strong representation from consumer or citizen groups, and all members being free of financial ties to drug and other interested companies.</p>
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<img alt="" src="https://images.theconversation.com/files/267971/original/file-20190408-2918-11cd1eo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/267971/original/file-20190408-2918-11cd1eo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/267971/original/file-20190408-2918-11cd1eo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/267971/original/file-20190408-2918-11cd1eo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/267971/original/file-20190408-2918-11cd1eo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/267971/original/file-20190408-2918-11cd1eo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/267971/original/file-20190408-2918-11cd1eo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Overdiagnosis can lead to the overtreatment of things that would never progress and never cause any harm.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/521751805?src=YyMFtMJUoJy-6i72m0aOog-1-1&size=huge_jpg">Ronald Rampsch/Shutterstock</a></span>
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<h2>Where to from here?</h2>
<p>Responding to overdiagnosis remains a complex and uncertain challenge, both for individuals, and those who run health systems. </p>
<p>But it’s clearly being taken more and more seriously. The World Health Organisation is co-sponsor of the <a href="https://www.preventingoverdiagnosis.net/">Preventing Overdiagnosis</a> conference in Sydney this year, where the science of the problem and solutions will be debated.</p>
<p>And just last week, leadership of the Nordic Federation of General Practitioners endorsed this proposal to reform the way diseases are defined. It’s likely others will follow suit, against strong resistance from vested interests.</p>
<p>But as we conclude in <a href="https://ebm.bmj.com/content/early/2019/04/11/bmjebm-2018-111148">today’s BMJ Evidence-Based Medicine article</a>, the time for change is now. We shouldn’t treat people as an ever-expanding marketplace for diseases, for the benefit of professional and commercial interests. We can no longer ignore the great harm to those unnecessarily diagnosed. </p>
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Read more:
<a href="https://theconversation.com/influential-doctors-arent-disclosing-their-drug-company-ties-110888">Influential doctors aren't disclosing their drug company ties</a>
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<img src="https://counter.theconversation.com/content/114621/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ray Moynihan receives funding from Australia's, National Health and Medical Research Council for an Early Career Fellowship. He is co-chair of the scientific committee organising the international scientific conference, Preventing Overdiagnosis, co-sponsored by the WHO. </span></em></p><p class="fine-print"><em><span>Paul Glasziou receives funding from an NHMRC program grant on overdiagnosis and overtreatment.</span></em></p>The threshold for diagnosing common conditions such as high blood pressure, chronic kidney disease and gestational diabetes have all lowered in recent years. But for whose benefit?Ray Moynihan, Assistant Professor, Bond UniversityPaul Glasziou, Professor of Medicine, Bond UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1129392019-03-14T10:39:20Z2019-03-14T10:39:20ZDoctors need to talk through treatment options better for black men with prostate cancer<figure><img src="https://images.theconversation.com/files/263745/original/file-20190313-123528-5miztm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Providing tools to help African-American men with prostate cancer make decisions about care can make a big difference. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/smiling-senior-african-american-man-doctors-151335698">michaeljung/Shutterstock.com</a></span></figcaption></figure><p>African-American men have the <a href="https://seer.cancer.gov/archive/csr/1975_2014/">highest risk</a> of being diagnosed with prostate cancer as well as dying from it compared to any other ethnic group in the U.S. This trend has remained unchanged for over four decades. </p>
<p>Although research has focused on identifying the biological differences that may lead to this difference, there’s growing <a href="https://www.ncbi.nlm.nih.gov/pubmed/29959759">evidence that distinct racial and ethnic disparities</a> in prostate cancer treatment, and the quality of medical care in African-American men, contribute to this disparity. </p>
<p>African-American men are <a href="https://prostatecancer.net/living/african-american-men/">less likely to receive</a> more aggressive treatments than their counterparts. And, if and when they do receive those treatments, they receive them later than their counterparts. For example, access to <a href="https://journals.sagepub.com/doi/abs/10.1177/107327480901600210">early effective survivorship treatments</a> such as <a href="https://www.cancer.org/cancer/prostate-cancer/treating/hormone-therapy.html">androgen deprivation therapies</a> remains a challenge in African-American patients. </p>
<p>Our multidisciplinary research program in cancer population science at the University of Virginia has been examining reasons for poor prostate cancer outcomes, especially in African-American patients. Recent, as yet unpublished research from our group highlights several issues related to <a href="https://ispor.confex.com/ispor/intl2019/research/papers/viewonly.cgi?username=90287&password=853194&EntryType=Paper">medication challenges in elderly prostate cancer survivors</a>. We found there is a <a href="https://journals.sagepub.com/doi/abs/10.1177/107327480901600210">clear link</a> between improved use of these treatments and reduced mortality. In addition, both access and use of these life-saving treatments remains low among African-American survivors. </p>
<h2>A history of gaps</h2>
<p>African-American prostate cancer patients face unique challenges in the treatment decision-making process. These include lower rates of understanding of treatment options, less time and interaction with medical care professionals and, often, poorer quality of medical care. Those challenges particularly affect both their access and compliance to medications, and, in turn, outcomes in these patients. </p>
<p>For example, a 69-year-old African American man whom we interviewed for our research, Mr. Tyler (name changed), along with his wife, Mrs. Tyler, sat in an exam room while his doctor told him he had stage 4 prostate cancer. Stage 4 cancer is cancer that has spread from its original site to distant organs and, in prostate cancer, even the bone. </p>
<p>Mr. Tyler was shocked. He had not noticed any health issues besides getting up in the middle of the night to urinate and some hip pain. He thought that was normal as men age. When he went to the clinic, he thought he had arthritis in his hip and would be prescribed pain medications for that. He could not imagine hearing that he had cancer. </p>
<p>He had not been to see a health care provider in about 12 years. He was always so busy at work and did not really feel comfortable going to a health care provider, having heard stories from family members and friends that other African-Americans are not treated well at the hospital. </p>
<p>The doctor gave Mr. Tyler a few options such as surgery, radiation and androgen deprivation therapy, considering his age, ethnicity, comorbidities and other related factors. But Mr. Tyler and his wife did not know what treatment options to seriously consider. </p>
<p>The health care provider gave a recommendation, but his wife was unsure. They were confused and anxious about making such a big and complex decision. The couple relied on information they received from speaking to friends, church members and relatives and ultimately made a decision, but it was not easy. And, it was not free from some regrets. Ultimately they chose to receive the radiation treatment and start the androgen deprivation treatment, which Mr. Tyler stopped because of discomfort. Mr. Tyler unfortunately died shortly after he discontinued treatment. </p>
<h2>Treatment decision process improvements may be paramount</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/263748/original/file-20190313-123554-1c0u5eu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/263748/original/file-20190313-123554-1c0u5eu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=421&fit=crop&dpr=1 600w, https://images.theconversation.com/files/263748/original/file-20190313-123554-1c0u5eu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=421&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/263748/original/file-20190313-123554-1c0u5eu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=421&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/263748/original/file-20190313-123554-1c0u5eu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=529&fit=crop&dpr=1 754w, https://images.theconversation.com/files/263748/original/file-20190313-123554-1c0u5eu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=529&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/263748/original/file-20190313-123554-1c0u5eu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=529&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Careful sharing of information and helping patients to decide treatment are especially important to help close the gap in outcomes between black men and other ethnic groups with prostate cancer.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-visiting-senior-male-patient-on-125889608">Monkey Business Images/Shutterstock.com</a></span>
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<p>This scenario of confusion and anxiety is not so uncommon. Cancer is a terrifying diagnosis, and making decisions about treatment can be overwhelming. </p>
<p>Studies have suggested that patients with cancer <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5411342/">feel more comfortable</a> expressing their concerns with their health care provider when there is a trusting and supportive relationship developed along with adequate time for treatment discussion. This in turn leads to more comfortable treatment decisions, which often works to improve patient outcomes. </p>
<p>Prostate cancer treatment in particular often brings harsh side effects that severely affect a man’s quality of life. These side effects include erectile dysfunction, hot flashes, muscle loss, hair loss and urinary issues such as incontinence. These may be short term, but they can last for years. </p>
<p>The matter is complicated because many of these harsh side effects stem from androgen deprivation therapies, which can improve survival. Because of the complicated nature of assessing the risk of side effects with the potential benefit of survival, the use of androgen deprivation therapies should carefully be considered by the patient and his doctor.</p>
<p>Research has shown that these treatment-related decisions are <a href="https://www.ncbi.nlm.nih.gov/pubmed/21377006">very different</a> in African-American prostate cancer patients compared to white patients and those residing in urban and rural communities. Therefore, there is a need to study treatment decision-making in both settings to formulate effective educational interventions. </p>
<h2>Aids that can help</h2>
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<img alt="" src="https://images.theconversation.com/files/263747/original/file-20190313-123531-1adtz5r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/263747/original/file-20190313-123531-1adtz5r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=270&fit=crop&dpr=1 600w, https://images.theconversation.com/files/263747/original/file-20190313-123531-1adtz5r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=270&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/263747/original/file-20190313-123531-1adtz5r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=270&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/263747/original/file-20190313-123531-1adtz5r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=340&fit=crop&dpr=1 754w, https://images.theconversation.com/files/263747/original/file-20190313-123531-1adtz5r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=340&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/263747/original/file-20190313-123531-1adtz5r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=340&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Providing information and discussing all options is especially important in the treatment of prostate cancer.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/african-couple-sitting-on-sofa-holds-1296270220">fizkes/Shutterstock.com</a></span>
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<p>In one of our recent studies, we found that <a href="https://www.ncbi.nlm.nih.gov/pubmed/27811543">decision aids may help</a>. Decision aids are electronic or paper tools involving a set of questions and information related to treatments. They are used to assist patients and caregivers in making informed decisions about the types of treatments and procedures, or both, that are more suitable for their particular case. </p>
<p>Decision aids are effective in a shared decision-making process, in which the doctor or nurse navigator sits down with a patient and walks through the process. There is active participation between the patient, caregiver and health care provider. </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/24470076">Decision aids</a> can help patients apply specific health information while actively participating in health-related decision-making. Primarily, decision aids that have been applied to prostate cancer have been focused on knowledge or treatment options only, which patients often complete themselves. These types of decision aids are quite limited and do not allow patients the time and true engagement with health care providers to really understand their disease and the options that are available, and ultimately become satisfied with that decision.</p>
<p>Decision aids are <a href="https://www.ncbi.nlm.nih.gov/pubmed/24422989">most effective</a> when they are tailored to the individual patient, rather than being generic. For example, researchers have developed an individualized decision support system BreastHealthDecisions.org, which represents a new approach to breast cancer prevention care. </p>
<p>In our study that developed an interactive decision aid for treatment decisions among advanced prostate cancer patients, we found that not only did the decision aid enhance patients’ and their caregivers’ understanding of the options that they had for treatment, but it also built more <a href="https://www.ncbi.nlm.nih.gov/pubmed/27811543">trust and engagement</a> between the patient and the health care provider, which is valuable. The study also revealed that by using the decision aid, patients were more concerned with the quality of their life after treatment than extending the number of years of life. </p>
<p>Developing decision support systems for prostate cancer is paramount as we move towards an era of precision medicine treatments, such as <a href="https://www.mdanderson.org/patients-family/diagnosis-treatment/care-centers-clinics/proton-therapy-center/conditions-we-treat/prostate-cancer.html">proton therapies</a>, which are used only after <a href="https://www.ncbi.nlm.nih.gov/pubmed/30730766">decision support system plans</a> are in place for the prostate cancer survivor.</p>
<p>Often, the conversations between health care providers and the patient are focused around the quantity of life. The patients in our study said they felt empowered enough through the use of the decision aid to discuss quality of life, and how that was a critical aspect within their conversations. </p>
<p>There is much work to do to provide optimal health care to patients with cancer, including African-Americans with cancer. Tailored decision aids that focus on the priorities of the patient and their caregivers and that promote trusting relationships with health care providers is key to helping patients feel satisfied with their health care decisions and have less regret.</p><img src="https://counter.theconversation.com/content/112939/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rajesh Balkrishnan receives funding from Merck and Company. </span></em></p><p class="fine-print"><em><span>Randy A. Jones receives funding from NIH.</span></em></p>Prostate cancer outcomes have differed between black men and other ethnic groups for decades. Could improving the way doctors talk and share information with black patients make a difference?Rajesh Balkrishnan, Professor, Public Health Sciences, University of VirginiaRandy A. Jones, Professor of Nursing, University of VirginiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1013312018-08-12T20:13:28Z2018-08-12T20:13:28ZIs it time to remove the cancer label from low-risk conditions?<figure><img src="https://images.theconversation.com/files/231570/original/file-20180812-2900-19rz7m6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many people associate the word cancer with major illness or death.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/599606216?src=EkdSPfaYPe_mqU4kw8kIAA-1-72&size=huge_jpg">Shutterstock</a></span></figcaption></figure><p>Over the past few decades, our understanding of cancer has changed. We now know some cancers <a href="https://prevention.cancer.gov/news-and-events/infographics/what-cancer-overdiagnosis">don’t grow or grow so slowly</a> that they’ll never cause medical problems. </p>
<p>But the way we label disease can harm. The use of more medicalised labels, including cancer, can <a href="https://bmjopen.bmj.com/content/7/7/e014129">increase levels of anxiety and the desire for more invasive treatments</a>.</p>
<p>Given this growing evidence, my colleagues and I argue in <a href="https://www.bmj.com/content/362/bmj.k3322">The BMJ</a> today that it may be time to stop telling people with very low-risk conditions that they have “cancer” if they’re unlikely to be harmed by it.</p>
<h2>Our understanding of cancer has changed</h2>
<p>Cancer screening for people who have no symptoms and the use of increasingly sensitive technologies can lead to <a href="https://www.bmj.com/content/350/bmj.h869">overdiagnosis</a> – a diagnosis that causes more harm than good. Overdiagnosis is most common in breast, prostate and thyroid cancer. </p>
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<a href="https://theconversation.com/most-people-want-to-know-risk-of-overdiagnosis-but-arent-told-41889">Most people want to know risk of overdiagnosis, but aren't told</a>
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<p>Thyroid cancer diagnoses, for example, have <a href="https://www.nejm.org/doi/full/10.1056/NEJMp1604412">dramatically increased</a> in developing countries. This has mainly been driven by an increase in the detection of papillary thyroid cancers. These are a sub-type of thyroid cancer which are often small (less than 2cm in size) and slow-growing.</p>
<p>But death rates from thyroid cancer remain largely unchanged. And tumour growth and spread in patients with small papillary thyroid cancer who choose surgery are <a href="https://www.sciencedirect.com/science/article/pii/S0748798317303700?via%3Dihub">similar to those</a> who just monitor their condition. </p>
<p>In fact, <a href="http://ascopubs.org/doi/abs/10.1200/JCO.2016.67.7419?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed&">autopsy studies spanning over 60 years</a> show thyroid “cancers” have always been common but often went undetected and didn’t cause harm. </p>
<h2>Impact of the cancer label</h2>
<p>Many people associate the word cancer with major illness or death. It can be frightening to hear. This association has been ingrained by public health messaging that cancer screening saves lives. </p>
<p>Although this promotion has had the best of intentions, it has also <a href="https://www.nejm.org/doi/full/10.1056/nejmp1209407">induced feelings of fear and vulnerability</a> in the population. It has then offered hope, through screening. </p>
<p>After decades, this messaging has resulted in <a href="https://jamanetwork.com/journals/jama/fullarticle/197942">highly positive attitudes towards cancer screening</a> and early treatment. It has also led to an increased, sometimes unwarranted, <a href="http://journals.sagepub.com/doi/abs/10.1177/0272989X05282639?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed&">desire for surgery</a>. </p>
<p><a href="https://bmjopen.bmj.com/content/7/7/e014129">Several studies</a> show the cancer label, and the use of medicalised labels in various other conditions, leads to higher levels of anxiety and perceived severity of the condition, as well as a greater preference for invasive treatments.</p>
<p>The increased desire for more aggressive treatments has been shown clinically in ductal carcinoma in situ (DCIS) of the breast (sometimes known as stage O breast cancer). Women are <a href="https://link.springer.com/article/10.1245%2Fs10434-014-4334-x">increasingly choosing</a> mastectomy and bilateral mastectomy (removal of one or both breasts) rather than lumpectomy (removal of the lump), even though these <a href="https://www.nytimes.com/2015/08/21/health/breast-cancer-ductal-carcinoma-in-situ-study.html">treatments do not change their odds</a> of dying of breast cancer. </p>
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Read more:
<a href="https://theconversation.com/treating-stage-0-breast-cancer-doesnt-always-save-womens-lives-so-should-we-screen-for-it-46624">Treating 'stage 0' breast cancer doesn't always save women's lives so should we screen for it?</a>
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<p>Similarly, in localised prostate cancer, active surveillance has been a recommended management option for a number of years, which means monitoring the condition and not providing immediate treatment. But men are <a href="https://www.nytimes.com/2016/05/25/health/prostate-cancer-active-surveillance-surgery-radiation.html">only beginning to avoid immediate treatment</a> and follow active surveillance at similar rates to men who choose surgery or radiation. </p>
<p>There is also evidence and informed speculation that melanoma in situ (also called stage 0 melanoma), small lung cancers, and some small kidney cancers may similarly be considered low risk and subject to overdiagnosis and overtreatment.</p>
<h2>A strategy to reduce overdiagnosis and overtreatment</h2>
<p>Removing the cancer label is <a href="https://www.sciencedirect.com/science/article/pii/S1470204513705989?via%3Dihub">one strategy</a> that has been proposed in recent years by international cancer experts to reduce overdiagnosis and overtreatment in some low-risk conditions. </p>
<p>The cancer label has previously been removed when there was clear evidence the condition was low-risk and very unlikely to cause harm. In 1998, “papilloma and grade 1 carcinoma of the bladder” was <a href="https://insights.ovid.com/pubmed?pmid=9850170">re-labelled</a> to “papillary urothelial neoplasia of low malignant potential”. The word carcinoma, which is another way of saying cancer, was dropped.</p>
<p>More recently, reference to “cancer” <a href="https://jamanetwork.com/journals/jamaoncology/fullarticle/2513250">was removed from a sub-type of papillary thyroid cancer</a>, which is identified after surgery. This was done to eliminate the need for ongoing follow-up and reduce any potential patient anxiety. </p>
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<a href="https://theconversation.com/informed-aussies-less-likely-to-want-a-prostate-cancer-test-36880">Informed Aussies less likely to want a prostate cancer test</a>
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<p>It’s vital we learn from these past examples. We also need to establish a formal evaluation of the impact that removing the cancer label will have on clinical practice and patient outcomes, to drive effective reform. </p>
<p>Ultimately, removing the cancer label will create controversy and take time. But the end result should better support appropriate evidence-based care for both future and current patients.</p><img src="https://counter.theconversation.com/content/101331/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Brooke Nickel receives funding from Sydney Catalyst and a National Health and Medical Research Council grant. </span></em></p>Labelling very low-risk conditions as cancers can cause unnecessary anxiety and lead to overtreatment.Brooke Nickel, PhD Candidate, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/968242018-05-22T10:46:32Z2018-05-22T10:46:32ZProstate cancer screening: An expert explains why new guidelines were needed<figure><img src="https://images.theconversation.com/files/219606/original/file-20180518-42200-t7yp70.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A blood test can reveal whether the level of a protein produced by prostate cells is elevated.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/blood-sample-psa-prostatespecific-antigen-positive-508660405?src=Jm9pm8ScMo-JYdyDWYs-FA-1-37">Ontakrai/Shutterstock.com</a></span></figcaption></figure><p>The U.S. Preventive Services Task Force has recently updated and modified its <a href="https://www.ncbi.nlm.nih.gov/pubmed/22801674">controversial 2012 recommendation</a> to abandon routine screening of all men using the prostate cancer screening blood test called the prostate specific antigen or PSA test. The USPSTF is a government task force comprised of members from the fields of primary care and preventive medicine that currently makes evidence-based recommendations about clinical preventive services.</p>
<p>The <a href="https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/prostate-cancer-screening1">updated recommendation</a> is that all U.S. men between the ages of 55 to 69 should consider PSA screening, after discussing the risks and benefits with their doctor. The panel recommended that men older than 70 should not undergo screening.</p>
<p>The 2012 recommendation was of <a href="http://auanet.mediaroom.com/2011-10-07-AUA-RESPONDS-TO-NEW-RECOMMENDATIONS-ON-PROSTATE-CANCER-SCREENING">great concern to physicians who treat prostate cancer</a>, survivors of the disease, and those at high risk due to race or hereditary factors.</p>
<p>As a urologist who treats and has cared for prostate cancer patients for 17 years, I witnessed firsthand how the controversies of PSA testing in 2012 led to significant confusion in both physicians and patients alike. The confusion may also have resulted in delay in diagnosis and an increase in the late-stage prostate cancer. A study released May 22, 2018 <a href="https://www.washingtonpost.com/national/health-science/after-long-decline-death-rates-from-prostate-cancer-stop-falling/2018/05/22/a937dc76-5da2-11e8-a4a4-c070ef53f315_story.html?noredirect=on&utm_term=.a9019749d6a3">reported an increase in late-stage incidence</a> and that deaths from prostate cancer had stopped decreasing.</p>
<h2>The scope of the problem</h2>
<p>The <a href="https://www.medicalnewstoday.com/articles/319859.php">prostate gland</a>, a small organ that is part of the male reproductive system and is situated between the bladder and urethra, is involved with urinary, fertility and sexual function. Cancer of the prostate gland is a result of uncontrolled growth of abnormal prostate cells within the gland. Early prostate cancer in its microscopic stage is commonly associated with no symptoms whatsoever, whereas advanced prostate cancer can spread beyond the prostate, into surrounding lymph nodes, and to the spine and other organs, resulting in pain, suffering and even death. </p>
<p>According to the American Cancer Society, prostate cancer is the second leading cause of cancer deaths in U.S. men, behind lung cancer. One in 9 men will be diagnosed with the disease in his lifetime and <a href="https://www.cancer.org/cancer/prostate-cancer/about/key-statistics.html">1 in 41 will die from prostate cancer</a>. </p>
<h2>PSA: A helpful but imperfect test</h2>
<p>In 1994, the Food and Drug Administration <a href="https://www.cancer.gov/types/prostate/psa-fact-sheet#q1">approved the use of the PSA blood test</a>, in addition to a digital rectal exam, to screen for prostate cancer. The PSA test measures a protein in the bloodstream called prostate-specific antigen that is produced by cells in the prostate gland. Certain conditions of the prostate, including an enlarged prostate, prostate inflammation, infection or prostate cancer can all cause an increase in PSA.</p>
<p>As such, PSA is a prostate-specific test but not necessarily a cancer-specific test. In other words, an elevated PSA does not always indicate the presence of cancer, yet may trigger the need for a prostate biopsy and expose a patient to the potential risks of pain, infection and bleeding only to find that no cancer exists. </p>
<p>Despite this, PSA testing has been invaluable in allowing physicians to detect prostate cancer at an earlier and more treatable stage. If PSA testing were abandoned, as recommended by the USPSTF in 2012, physicians would have to rely solely upon physical examination alone for cancer detection, which would risk detecting the disease too late. This, we feared, would translate into cancers that may already have spread beyond the prostate gland where treatments are far less effective. </p>
<h2>To treat or not to treat: A troubling, complex disease</h2>
<p>Prostate cancer is a complex disease, not only from a diagnosis, but also from a treatment standpoint. As with many cancers, early detection can be life-saving. But not all prostate cancers are lethal; some grow slowly and will never threaten a man’s life or even health. Determining which cancers are dangerous and therefore require treatment has been a great challenge. </p>
<p>Prior to 2012, widespread PSA screening increased the detection of potentially aggressive prostate cancers, but it also led to the overdiagnosis of slow-growing, nonlethal cancers. Treatment of these less aggressive cancers, although curative, left men with unwanted side effects of treatment, such as erectile and urinary difficulties. Therefore, finding the right group of men who benefit the most from prostate cancer screening and treatment based on age, risk factors and life expectancy is at the root of this controversy. </p>
<h2>The screening guidelines change for PSA testing</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/219799/original/file-20180521-14957-1cl2i9i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/219799/original/file-20180521-14957-1cl2i9i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=429&fit=crop&dpr=1 600w, https://images.theconversation.com/files/219799/original/file-20180521-14957-1cl2i9i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=429&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/219799/original/file-20180521-14957-1cl2i9i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=429&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/219799/original/file-20180521-14957-1cl2i9i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=539&fit=crop&dpr=1 754w, https://images.theconversation.com/files/219799/original/file-20180521-14957-1cl2i9i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=539&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/219799/original/file-20180521-14957-1cl2i9i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=539&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Prostate cancer survivor and teacher Michael Jackson. African-American men with a first- or second-degree relative may be at higher risk and therefore may need more aggressive screening.</span>
<span class="attribution"><a class="source" href="https://visualsonline.cancer.gov/details.cfm?imageid=9812">National Cancer Institute</a></span>
</figcaption>
</figure>
<p>Prior to the 2012 recommendations by the USPSTF, screening using both the PSA and digital prostate examination was recommended on an annual basis for all U.S. men. Because of concerns about overtreatment, however, a USPSTF panel in 2012 examined the evidence surrounding PSA testing. The panel released its recommendation against routine PSA testing for all men based on a lack of convincing evidence of a survival benefit to widespread PSA testing.</p>
<p>Based on a <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=Shoag+J.+J+Urol+2016+196%3A1047">national survey</a>, there was an immediate 40 percent reduction in PSA testing performed by primary care physicians in the first year after the 2012 recommendation. More concerning, 65 percent of these physicians also stopped performing digital prostate examinations, therefore abandoning <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=Shoag+J.+J+Urol+2016+196%3A1047">any form of prostate cancer screening</a>. </p>
<p>Physicians began to see a disturbing trend. <a href="https://www.ncbi.nlm.nih.gov/pubmed/27402061">More men diagnosed with prostate cancer</a> had aggressive disease, as well as metastatic cancer that had already spread beyond the prostate gland. In sharp contrast, the <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=Catalona+WJ+NEJM+1991+324%3A+1156">introduction and utilization of PSA in the early 1990s</a> resulted in detecting prostate cancer at an earlier and more curable stage with less advanced, incurable disease at diagnosis.</p>
<p>In response to the 2012 recommendation, the American Urological Association <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=Carter+HB+J+Urol+2013+190(2)%3A419">performed its own review</a> and determined that:</p>
<ul>
<li>The subgroup of men who gain the greatest benefit to routine PSA screening are between the ages of 55 and 69.</li>
<li>A relaxed screening interval of every two to four years versus annually may reduce the harms of overdiagnosis.</li>
<li>Patients should have a discussion about their individual risk and the potential benefits of PSA testing with their physician, especially in men with higher than average risk (i.e. African-Americans and those who have many first- and second-degree male relatives with a history of the disease).</li>
</ul>
<p>In addition, to address the concern of overtreatment, urologists have moved to a more selective approach toward treatment of cancers, especially those that are of low risk of progression and spread. </p>
<p>For such cancers, urologists have begun to increasingly advocate a monitoring strategy called active surveillance and advised treatment only if and when the disease begins to show early signs of growth. These recommendations addressed the concern of overtreatment by reducing the unnecessary and premature exposure of men to adverse treatment-related side effects. </p>
<p>Many state legislatures released their own prostate cancer screening recommendations based upon their unique patient population. For example, the <a href="http://prostatecanceradvisorycouncil.org/">Florida Prostate Cancer Advisory Council (PCAC)</a> recommended that men who are at higher-than-average risk, including African-American men and Caribbean men of African ancestry, be encouraged to get tested as early as age 40. Both populations are present in Florida at a <a href="https://www.census.gov/quickfacts/fact/table/FL,US/PST120217#viewtop">higher percentage than the national average</a>.</p>
<h2>Men 55 to 69: Talk to your doctor about PSA testing</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/219816/original/file-20180521-14953-19pwefb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/219816/original/file-20180521-14953-19pwefb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=475&fit=crop&dpr=1 600w, https://images.theconversation.com/files/219816/original/file-20180521-14953-19pwefb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=475&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/219816/original/file-20180521-14953-19pwefb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=475&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/219816/original/file-20180521-14953-19pwefb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=597&fit=crop&dpr=1 754w, https://images.theconversation.com/files/219816/original/file-20180521-14953-19pwefb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=597&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/219816/original/file-20180521-14953-19pwefb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=597&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The author counsels an older patient at UF Health in Gainesville, Fla.</span>
<span class="attribution"><span class="source">Mindy Miller/UF Health</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>The recent revised recommendations included a review of evidence published since 2012. The USPSTF panel concluded that men aged 55-69 years should consider periodic PSA screening, citing a small benefit of reducing death from prostate cancer in this age range. However, the panel discouraged testing in men older than 70 and were unable to make specific recommendations for men at increased risk for prostate cancer based on race and family history.</p>
<p>Although the new USPSTF recommendations more closely align with the national urologic association and most major physician group recommendations, the national group and the Florida advisory council believe that even the current recommendations fall short. They do not address men with especially high risk for prostate cancer as well as healthy men 70 and older, with a greater than 10-year life expectancy, who in our view still benefit from PSA screening.</p>
<p>Based on the new guidelines, I hope that PSA testing will be on the minds of men. I urge them to talk candidly with their physician about whether prostate cancer screening including a PSA test and a prostate examination is right for them based upon their individual risk. The message is clear that the answer is not to stop PSA screening altogether, but to screen smarter and treat smarter based upon each man’s unique circumstance.</p><img src="https://counter.theconversation.com/content/96824/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Li-Ming Su does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Prostate cancer is the second deadliest cancer among men, but not all types of the disease are as deadly as others. That has led to confusion over screening. An expert explains why new guidelines make sense.Li-Ming Su, David A. Cofrin Professor of Urologic Oncology and Chair of the Department of Urology, University of FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/954402018-05-06T20:15:11Z2018-05-06T20:15:11ZEvery cancer patient should be prescribed exercise medicine<figure><img src="https://images.theconversation.com/files/217244/original/file-20180502-153873-1jx9usw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Most doctors and nurses agree exercise is beneficial but don’t routinely prescribe exercise as part of their patients' cancer treatment plan.</span> <span class="attribution"><span class="source">Photo credit: Exercise Oncology Team at Australian Catholic University</span></span></figcaption></figure><p>Every <a href="https://canceraustralia.gov.au/affected-cancer/what-cancer/cancer-australia-statistics">four minutes</a> someone in Australia is diagnosed with cancer. Only one in ten of those diagnosed will exercise enough during and after their treatment. But every one of those patients <a href="https://www.ncbi.nlm.nih.gov/pubmed/28453622">would benefit from exercise</a>.</p>
<p>I’m part of Australia’s peak body representing health professionals who treat people with cancer, the <a href="https://www.cosa.org.au/">Clinical Oncology Society of Australia</a>. Today we’re joining 25 other cancer organisations to <a href="https://www.cosa.org.au/publications/position-statements.aspx">call for exercise to be prescribed</a> to all cancer patients as part of routine cancer care.</p>
<p>Published today in the <a href="https://www.mja.com.au/journal/2018/209/6/clinical-oncology-society-australia-position-statement-exercise-cancer-care">Medical Journal of Australia</a>, our plan is to incorporate exercise alongside surgery, chemotherapy and radiotherapy to help counteract the negative effects of cancer and its treatment. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-exercise-should-be-added-to-cancer-treatment-plans-12288">Why exercise should be added to cancer treatment plans</a>
</strong>
</em>
</p>
<hr>
<h2>What are we calling for?</h2>
<p>Historically the advice to cancer patients was to rest and avoid activity. We now know this advice may be harmful to patients, and every person with cancer would benefit from exercise medicine. </p>
<p>Most doctors and nurses agree exercise is beneficial but don’t routinely prescribe exercise as part of their patients’ cancer treatment plan. </p>
<p>It is our position that all health professionals involved in the care of people with cancer should:</p>
<ol>
<li>view and discuss exercise as a standard part of the cancer treatment plan</li>
<li>recommend people with cancer adhere to exercise guidelines</li>
<li>refer patients to an exercise physiologist or physiotherapist with experience in cancer care.</li>
</ol>
<h2>Why prescribe exercise?</h2>
<p>Cancer patients who exercise regularly experience fewer and less severe side effects from treatments. They also have a lower relative risk of <a href="https://www.ncbi.nlm.nih.gov/pubmed/27407093">cancer recurrence</a> and a lower relative risk of <a href="https://www.ncbi.nlm.nih.gov/pubmed/26385207">dying from their cancer</a>.</p>
<p>If the effects of exercise could be encapsulated in a pill, it would be prescribed to every cancer patient worldwide and viewed as a major breakthrough in cancer treatment. If we had a pill called exercise it would be demanded by cancer patients, prescribed by every cancer specialist, and subsidised by government.</p>
<p>Cancer and its treatment can have a devastating effect on people’s lives, causing serious health issues that compromise their physical and mental well-being. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/xIQh4fUZkJs?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Here’s why exercise is a new contender in the fight against cancer. TEDxPerth.</span></figcaption>
</figure>
<p>Research shows exercise can help cancer patients tolerate aggressive <a href="https://www.ncbi.nlm.nih.gov/pubmed/17785708">treatments</a>, minimise the <a href="https://www.ncbi.nlm.nih.gov/pubmed/28453622">physical declines</a> caused by cancer, counteract <a href="https://www.ncbi.nlm.nih.gov/pubmed/28253393">cancer-related fatigue</a>, relieve <a href="https://www.ncbi.nlm.nih.gov/pubmed/22068286">mental distress</a> and improve <a href="https://www.ncbi.nlm.nih.gov/pubmed/22895974">quality of life</a>. </p>
<p>When appropriately prescribed and monitored, exercise is <a href="https://www.ncbi.nlm.nih.gov/pubmed/20559064">safe</a> for people with cancer and the risk of complications is relatively low.</p>
<p>Implementing exercise medicine as part of routine cancer care not only has the potential to change people’s lives but to also save money. People with cancer who exercise have <a href="https://www.ncbi.nlm.nih.gov/pubmed/29527464">lower medical expenses</a> and spend <a href="https://www.ncbi.nlm.nih.gov/pubmed/22081271">less time away from work</a>.</p>
<h2>What exactly should be prescribed?</h2>
<p>Exercise specialists can prescribe exercise in a similar way that doctors prescribe medications; by knowing how cancer impacts our health, and understanding how certain exercises improve the structure and function of the body’s systems.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/strength-training-can-have-unique-health-benefits-and-it-doesnt-have-to-happen-in-a-gym-84904">Strength training can have unique health benefits, and it doesn't have to happen in a gym</a>
</strong>
</em>
</p>
<hr>
<p>These individualised programs involve specific types of exercises, performed at precise intensities and volumes based on a mechanism of action and dosage needed to counteract the negative effects of cancer.</p>
<p>The <a href="https://www.ncbi.nlm.nih.gov/pubmed/20559064">evidence-based guidelines</a> recommend people with cancer be as physically active as their current ability and conditions allow. For significant health benefits, they should aim for:</p>
<ol>
<li><p>at least 150 minutes of moderate intensity aerobic exercise weekly (such as walking, jogging, cycling, swimming)</p></li>
<li><p>two to three resistance exercise session each week involving moderate to vigorous intensity exercises targeting the major muscle groups (such as weight lifting).</p></li>
</ol>
<p>These recommendations should be tailored to the individual’s abilities to minimise the risk of complications and maximise the benefits. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/217749/original/file-20180504-166881-v0xzrl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/217749/original/file-20180504-166881-v0xzrl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/217749/original/file-20180504-166881-v0xzrl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=319&fit=crop&dpr=1 600w, https://images.theconversation.com/files/217749/original/file-20180504-166881-v0xzrl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=319&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/217749/original/file-20180504-166881-v0xzrl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=319&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/217749/original/file-20180504-166881-v0xzrl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=401&fit=crop&dpr=1 754w, https://images.theconversation.com/files/217749/original/file-20180504-166881-v0xzrl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=401&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/217749/original/file-20180504-166881-v0xzrl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=401&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Exercise is safe for people with cancer and can be tailored for the individual.</span>
<span class="attribution"><span class="source">Photo Credit: Exercise Oncology Team at Australian Catholic University</span></span>
</figcaption>
</figure>
<h2>How will patients fill the prescription?</h2>
<p>Getting this much exercise may seem out of reach for many people with cancer. But exercise specialists who have experience in cancer care can help. They’ll design an individual program based on the patient’s disease, how they’ve responded to treatment and the anticipated trajectory of their health status.</p>
<p>Online directories can help find <a href="https://www.essa.org.au/find-aep/">accredited exercise physiologists</a> and <a href="https://choose.physio/">physiotherapists</a> practising nearby. These services are eligible for subsidies through Medicare and private health insurance.</p>
<p>Or patients can opt for structured <a href="http://www.exmedcancer.org.au/">cancer-specific exercise medicine programs</a> such as EX-MED Cancer, which I lead. Such programs are designed to maximise the safety and effectiveness of exercise medicine for cancer patients.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/a-prescription-for-better-health-exercise-after-prostate-cancer-40223">A prescription for better health: exercise after prostate cancer</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/95440/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Prue Cormie is the Chair of the Exercise and Cancer Group within the Clinical Oncology Society of Australia and leads the Exercise and Sports Science Australia Cancer Special Interest Group. She is a Principal Research Fellow at Australian Catholic University and holds honorary clinical exercise physiologist positions at Peter McCallum Cancer Centre, Austin Health (Olivia Newton-John Cancer Wellness and Research Centre) and Royal Melbourne Hospital. Prue Cormie receives funding from NHMRC, Cancer Australia, Prostate Cancer Foundation of Australia, National Breast Cancer Foundation, Cancer Councils and the Victorian Government.
</span></em></p>Historically the advice to cancer patients was to rest and avoid activity. We now know this advice may be harmful to patients, and that every person with cancer would benefit from exercise medicine.Prue Cormie, Principal Research Fellow in Exercise & Cancer, Australian Catholic UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/949562018-04-27T10:12:52Z2018-04-27T10:12:52ZWhy cancer cells go to sleep<figure><img src="https://images.theconversation.com/files/215412/original/file-20180418-163978-ajs5uy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Prostate cancer cell, viewed with a scanning electron microscope.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/202719580?src=3_jdSrXklM_AUW9qJtKSZQ-1-7&size=medium_jpg">royaltystockphoto.com/Shutterstock.com</a></span></figcaption></figure><p>Cancer has always been thought of as something that grows rapidly and uncontrollably, but this view may be wrong. New evidence suggests that cancer alternatively uses the “accelerator” and the “brake” in order to survive. </p>
<p>If you plot the growth of prostate cancer tumour progression over years, you get a graph that looks something like this:</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/215607/original/file-20180419-163991-18uio4s.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/215607/original/file-20180419-163991-18uio4s.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=311&fit=crop&dpr=1 600w, https://images.theconversation.com/files/215607/original/file-20180419-163991-18uio4s.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=311&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/215607/original/file-20180419-163991-18uio4s.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=311&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/215607/original/file-20180419-163991-18uio4s.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=391&fit=crop&dpr=1 754w, https://images.theconversation.com/files/215607/original/file-20180419-163991-18uio4s.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=391&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/215607/original/file-20180419-163991-18uio4s.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=391&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Figure 1. An example of prostate cancer progression.</span>
<span class="attribution"><span class="source">Modified from: http://www.cell.com/trends/molecular-medicine/fulltext/S1471-4914(15)00034-9</span></span>
</figcaption>
</figure>
<p>The graph shows that prostate cancer cells alternate periods of rapid growth with periods of dormancy. In the above example, the tumour will grow to the point where it starts to produce symptoms and the patient seeks treatment – which usually involves cutting the tumour out.</p>
<p>Surgery is often effective but, for some unfortunate patients, their cancer will return. At this point it is often treated with hormone therapy and chemotherapy. But even these treatments don’t always spell the end of the cancer. For some patients, the cancer will recur after a period of dormancy.</p>
<p>During the periods of dormancy, which could last several years, the patient will often have no symptoms and the tumour will be undetectable using the usual diagnostic tools. Until recently, we knew very little about these periods. However, research conducted by my group and by other scientists suggests that cancer dormancy is a crucial time for tumour progression. </p>
<h2>Dangers of cancer dormancy</h2>
<p>To understand why dormancy is useful to cancer cells, we need to examine the factors that can stop tumour progression. Cancer cells face three main challenges to their survival and growth. First, they need to <a href="http://www.cancerresearchuk.org/about-cancer/what-is-cancer/body-systems-and-cancer/the-immune-system-and-cancer">deceive the immune system</a>, which is able to eliminate most tumours. Second, they need to survive anti-cancer therapies, and, third, they need to invade distant organs and generate metastases.</p>
<p>Cancer dormancy is <a href="http://www.springer.com/gb/book/9783319592404">essential</a> to meet all these challenges. During the periods of dormancy, cancer cells reshape their genetic make-up and get ready for the next stage of progression. Without dormancy, cancer cells would not be able to survive in a new environment or become resistant to the attacks of the immune system. So it is important to learn how to detect dormant cancer cells, and how to kill them.</p>
<p>Detecting dormant cells is not easy, though. Dormant tumours are often small and don’t produce symptoms, so patients are often unaware of them and conventional diagnostic tools are unable to “see” them. Also, dormant cancer cells are often in slow-metabolism mode, like hibernating animals. So even some sophisticated diagnostic techniques, such as PET scans, often overlook dormant tumours. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/215597/original/file-20180419-163966-pglhgs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/215597/original/file-20180419-163966-pglhgs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=414&fit=crop&dpr=1 600w, https://images.theconversation.com/files/215597/original/file-20180419-163966-pglhgs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=414&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/215597/original/file-20180419-163966-pglhgs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=414&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/215597/original/file-20180419-163966-pglhgs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=520&fit=crop&dpr=1 754w, https://images.theconversation.com/files/215597/original/file-20180419-163966-pglhgs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=520&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/215597/original/file-20180419-163966-pglhgs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=520&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Dormant cancer cells share some similarities with hibernating animals.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/788986813?src=mZXXsesHXItQnQL56YPUYg-1-0&size=medium_jpg">Breck P. Kent/Shutterstock.com</a></span>
</figcaption>
</figure>
<h2>Detection and treatment</h2>
<p>So how do we detect these dangerous sleeping cells? Fortunately, new studies are shedding light on the characteristics of dormant cancer cells. For example, our research, in collaboration with the <a href="http://www.bccrc.ca/dept/et/personnel%20-%20content/principal-investigators/dr.-yuzhuo-wang">BC Cancer Agency</a> in Canada, has looked at the RNA produced by dormant and proliferating cancer cells. RNA is a very important molecule that carries the genetic information from DNA (the blueprint) to proteins (the cells’ workhorses). </p>
<p>We have shown that some small RNAs are <a href="http://oro.open.ac.uk/50028/1/41598_2017_Article_3731.pdf">specifically expressed</a> by dormant cancer cells. Since these RNAs can be measured in urine and blood samples, we, and others, are trying to develop new diagnostic tools to detect these molecules. If we are successful, we will be able to develop blood or urine-based diagnostic kits that will help doctors identify dormant tumours before they become too big to effectively treat.</p>
<p>Once dormant cancer cells have been identified, they need to be eliminated. Unfortunately, since these cancer cells are metabolically inactive, they are less likely to be killed by conventional chemotherapy, so targeting them is difficult. Difficult, but hopefully not impossible. </p>
<p>A number of new studies show that dormant cells might have weak spots. For example, experiments have shown that some <a href="https://www.statnews.com/2018/04/11/cancer-tumor-cells-mice-metastasis-nsaid/">nonsteroidal anti-inflammatory drugs</a> could stop dormant cancer cells that generate metastasis from “waking up”. If these results are confirmed by clinical trials, we will soon be able to offer the patients treatments that specifically target dormant cancer cells.</p><img src="https://counter.theconversation.com/content/94956/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Francesco Crea has received funding from Cancer Research UK, ASCO, Santander, Prostate Cancer Foundation BC and the Michael Smith Foundation, . He is affiliated with the European Association for Cancer Research. </span></em></p>Cancer doesn’t just grow uncontrollably. It has a smarter strategy than that.Francesco Crea, Lecturer in Life Sciences, The Open UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/932842018-03-16T03:52:41Z2018-03-16T03:52:41ZPSA testing for prostate cancer is only worth it for some<figure><img src="https://images.theconversation.com/files/210743/original/file-20180316-104673-mgmzig.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many men who have prostate cancer will die with it, rather than of it.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>A recent <a href="https://jamanetwork.com/journals/jama/article-abstract/2673968">UK study</a> showed no significant difference in survival between men who had a single prostate-specific antigen (PSA) test – a blood test used to detect prostate cancer – and those who didn’t, after about ten years of follow-up. This was despite the test being responsible for more prostate cancers being diagnosed.</p>
<p>It was the largest ever randomised trial on this question, involving 400,000 men aged 50-69 without prostate symptoms. The findings were in keeping with <a href="http://www.cochrane.org/CD004720/PROSTATE_screening-for-prostate-cancer">previously published trials of PSA screening</a>, which, other than one exception, have also shown no improvement in survival. </p>
<p>The prostate-specific antigen is a protein produced by the prostate gland and secreted into semen. It can be measured in the blood as an indicator of diseases affecting the prostate gland. Since the 1980s, PSA tests have been used for the diagnosis and follow-up of prostate cancer. However, its use as a screening test for prostate cancer remains controversial. </p>
<h2>What’s the controversy?</h2>
<p>PSA testing leads to the diagnosis of some cancers that might never have caused problems and thus would not have been diagnosed based on symptoms. This is referred to as “over-diagnosis”. </p>
<p>This phenomenon is of concern with any screening program, such as <a href="https://canceraustralia.gov.au/publications-and-resources/position-statements/overdiagnosis-mammographic-screening/pdf">mammograms for breast cancer</a>. Over-diagnosis needs to be weighed against the benefits of screening in finding more serious cancers at an earlier and more curable stage. </p>
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Read more:
<a href="https://theconversation.com/psa-screening-and-prostate-cancer-over-diagnosis-8568">PSA screening and prostate cancer over-diagnosis</a>
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<p>This is further compounded by the fact prostate cancer <a href="https://www.aihw.gov.au/getmedia/3da1f3c2-30f0-4475-8aed-1f19f8e16d48/20066-cancer-2017.pdf.aspx?inline=true">typically occurs in elderly men</a>. And it can sometimes be a period of many years from when prostate cancer is diagnosed to when it spreads beyond the prostate or becomes life-threatening. This is why it’s often said “men die <em>with</em> prostate cancer rather than <em>of</em> prostate cancer”. </p>
<p>Treatment of indolent prostate cancers isn’t likely to benefit men and is referred to as “over-treatment”. </p>
<p>Some may consider these factors enough to suggest PSA testing for prostate cancer should be abandoned altogether. But the fact remains that an estimated 3,500 men <a href="https://www.aihw.gov.au/getmedia/3da1f3c2-30f0-4475-8aed-1f19f8e16d48/20066-cancer-2017.pdf.aspx?inline=true">will die of prostate cancer</a> in Australia this year. Many more will suffer symptoms, such as pain from incurable prostate cancer, and undergo treatments such as chemotherapy with serious side effects. </p>
<p>PSA testing remains the best way for the early detection and curative treatment of such aggressive prostate cancer. But more can be done to resolve the dilemma.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/210700/original/file-20180315-104699-1bzbyx9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/210700/original/file-20180315-104699-1bzbyx9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/210700/original/file-20180315-104699-1bzbyx9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/210700/original/file-20180315-104699-1bzbyx9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/210700/original/file-20180315-104699-1bzbyx9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/210700/original/file-20180315-104699-1bzbyx9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/210700/original/file-20180315-104699-1bzbyx9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/210700/original/file-20180315-104699-1bzbyx9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Using a PSA test for prostate cancer remains controversial.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
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<h2>Improving on the PSA test</h2>
<p>Researchers are looking for tests that can detect aggressive prostate cancer better than PSA testing. A handful of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4774403/pdf/br-04-03-0263.pdf">the numerous markers tested</a> have entered clinical (human) use, but none have been shown to perform better than PSA as a screening test. </p>
<p>In current practice, <a href="https://www.cancer.org/cancer/prostate-cancer/early-detection/tests.html">refinements of the PSA</a>, including subtypes of measurable PSA, rates of change of PSA over time, and various scores based on PSA, can be used to more precisely assess a man’s risk of having prostate cancer. </p>
<p>To further optimise the benefits of PSA testing, it needs to be targeted at the appropriate age group, namely 50- to 69-year-old men. Older men (or those with reduced life expectancy because of medical illness) are unlikely to benefit from prostate cancer treatment and should not undergo PSA testing.</p>
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Read more:
<a href="https://theconversation.com/more-harm-than-good-rethinking-routine-prostate-cancer-screening-8612">More harm than good: rethinking routine prostate cancer screening</a>
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<p>On the other hand, men in their 40s (or younger) usually have a very low risk of developing prostate cancer. They should only undergo PSA testing if there is a family history (which confers an increased risk). These recommendations form the centrepiece of <a href="http://www.prostate.org.au/media/611493/PSA-Testing-Guidelines-Short-Form.pdf">clinical practice guidelines</a> developed by the Prostate Cancer Foundation of Australia (PCFA) in 2016. </p>
<p>It remains uncertain exactly how often PSA tests should be repeated to be most effective. In line with a prominent <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4089887/pdf/nihms513678.pdf">European trial</a> that demonstrated the greatest reduction in prostate cancer deaths, the PCFA guidelines recommend PSA tests every two years. </p>
<h2>If you have an abnormal PSA test</h2>
<p>Further steps can be taken after a PSA test to reduce potential harms of over-diagnosis and over-treatment. Firstly, it’s essential to obtain confirmation of the high reading and check whether there’s a cause other than cancer, such as a urinary tract infection, blockage or trauma (even from a long bicycle ride). </p>
<p>If an abnormal PSA reading is confirmed, prostate biopsy is carried out as the definitive diagnostic test for prostate cancer. Infectious risks of prostate biopsy can be mitigated by alternative techniques such as the <a href="http://onlinelibrary.wiley.com/doi/10.1111/bju.12536/epdf">transperineal approach</a> where the biopsy needle passes through skin rather than through the rectum as is usual. Many Australian centres now use transperineal biopsy. </p>
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Read more:
<a href="https://theconversation.com/pull-your-finger-out-doc-rectal-exams-arent-the-best-way-to-find-prostate-cancer-48743">Pull your finger out, doc, rectal exams aren't the best way to find prostate cancer</a>
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<p>Work from Australian researchers has also shown that <a href="https://www.racgp.org.au/afp/2015/august/multiparametric-mri-in-the-diagnosis-of-prostate-cancer-%E2%80%93-a-generational-change/">magnetic resonance imaging (MRI)</a> scans may help further refine biopsy accuracy. The use of MRI as an adjunct to prostate biopsy appears to enhance the detection of aggressive prostate cancer and reduce the detection of indolent prostate cancer. </p>
<p>Current use of prostate MRI in Australia continues to have some accessibility limitations, which will hopefully reduce over time. Since MRI results are very dependent on the power of the scanning magnet, the technique of the scan and the expertise of the interpreting radiologist, they are not yet widely available. There are also significant expenses, since a Medicare rebate for prostate MRI is still <a href="http://www.msac.gov.au/internet/msac/publishing.nsf/content/1397-public">under review</a>.</p>
<h2>After diagnosis</h2>
<p>If a man is diagnosed with prostate cancer, it’s important that treatment decisions are tailored individually. Most importantly, low-risk prostate cancers should be increasingly kept under <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4974765/pdf/12885_2016_Article_2655.pdf">active surveillance</a>, thereby delaying, or perhaps even altogether avoiding, treatment and related side effects. </p>
<p>Conversely, high-risk prostate cancer needs early and aggressive treatment to achieve the best possible outcomes. Currently available methods for working out how prostate cancer might behave draw on information from PSA tests, physical examination, scans and biopsy. Emerging technologies such as <a href="http://www.prostatemarkers.org/markers/who-to-treat">genomic tests</a> may help further refine the accuracy of this predictive process. </p>
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Read more:
<a href="https://theconversation.com/giving-men-choice-the-case-for-routine-prostate-cancer-screening-8633">Giving men choice: the case for routine prostate cancer screening</a>
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<p>Advances in clinical practice have helped reduce some of the harms of PSA testing while preserving the potential benefits. However, ongoing work is needed to further improve outcomes for men with prostate cancer. There are risks and benefits men need to consider in the process of making an <a href="http://www.prostate.org.au/media/611493/PSA-Testing-Guidelines-Short-Form.pdf">informed decision</a> in consultation with their GP.</p><img src="https://counter.theconversation.com/content/93284/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Shomik Sengupta treats men with prostate cancer both as a private practitioner and as an employee of Eastern Health. He has been a recipient of grant funding from Cancer Australia for clinical trials research, although not in prostate cancer. He is affiliated with Monash University as Professor of Surgery at the Eastern Health Clinical School.
Shomik is also a Board Director and a member of the Scientific Advisory Committee of the Australia & New Zealand Uro-Genital & Prostate (ANZUP) Cancer Trials Group, which runs clinical trials for prostate cancer treatment. Shomik is also the leader of the Genito-urinary Oncology Special Advisory Group within the Urological Society of Australia & New Zealand (USANZ), which is the professional organisation representing urologists, who treat men with prostate cancer.</span></em></p>Since the 1980s, PSA tests have been used for the diagnosis and follow-up of prostate cancer. However, its use as a screening test for prostate cancer remains controversial.Shomik Sengupta, Professor of Surgery, Eastern Health Clinical School, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/902212018-01-18T19:17:24Z2018-01-18T19:17:24ZA new blood test can detect eight different cancers in their early stages<figure><img src="https://images.theconversation.com/files/202371/original/file-20180117-53310-9zjg6j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Liquid biopsy is less invasive than standard biopsy, where a needle is put into a solid tumour to confirm a cancer diagnosis.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Researchers have <a href="http://science.sciencemag.org/content/early/2018/01/17/science.aar3247">developed a blood test</a> that can detect the presence of eight common cancers. Called CancerSEEK, the blood test detects tiny amounts of DNA and proteins released into the blood stream from cancer cells. This can then indicate the presence of ovarian, liver, stomach, pancreatic, oesophageal, bowel, lung or breast cancers.</p>
<p>Known as a liquid biopsy, the test is distinctly different to a standard biopsy, where a needle is put into a solid tumour to confirm a cancer diagnosis. CancerSEEK, is also far less invasive. It can be performed without even knowing a cancer is present, and therefore allow for early diagnosis and more chance of a cure. </p>
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Read more:
<a href="https://theconversation.com/interactive-body-map-what-really-gives-you-cancer-52427">Interactive body map: what really gives you cancer?</a>
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<p>The test has been shown to reliably detect early stage and curable cancers. It has also been found to rarely be positive in people who don’t have cancer. This prevents significant anxiety and further invasive tests for those who don’t need them. </p>
<p>Several cancers can be screened for at once, and the test can be performed at the same time as routine blood tests, such as a cholesterol check. But the test is still some years away from being used in the clinic.</p>
<h2>How the test works</h2>
<p>Often long before causing any symptoms, even very small tumours will begin to release minute amounts of mutated DNA and abnormal proteins into blood. While DNA and proteins are also released from normal cells, the DNA and proteins from cancer cells are unique, containing multiple changes not present in normal cells. </p>
<p>The newly developed blood-based cancer DNA test is exquisitely sensitive, accurately detecting one mutated fragment of DNA among 10,000 normal DNA fragments, literally “finding the needle in the haystack”.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/202381/original/file-20180118-114739-vxgc1e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/202381/original/file-20180118-114739-vxgc1e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/202381/original/file-20180118-114739-vxgc1e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/202381/original/file-20180118-114739-vxgc1e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/202381/original/file-20180118-114739-vxgc1e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/202381/original/file-20180118-114739-vxgc1e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/202381/original/file-20180118-114739-vxgc1e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/202381/original/file-20180118-114739-vxgc1e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Tumours release mutated DNA and abnormal proteins into blood.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
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</figure>
<p>We used CancerSEEK in just over 1,000 people with different types of early stage cancers. It was shown to accurately detect the cancer, including in 70% or more of pancreas, ovary, liver, stomach and esophageal cancers. For each of these tumour types there are currently no screening tests available – blood based or otherwise. </p>
<p>Along with cancer detection, the blood test accurately predicted what type of cancer it was in 83% of cases. </p>
<p>Published in the journal <a href="http://science.sciencemag.org/content/early/2018/01/17/science.aar3247">Science</a>, the research was led by a team from John Hopkins University, with collaboration from Australian scientists at the Walter and Eliza Hall Institute. </p>
<h2>Why it’s important</h2>
<p>Steady progress continues to be made in the treatment of advanced cancers, including major gains in life expectancy. But this can come at significant physical and financial cost. Early diagnosis remains the key to avoiding the potentially devastating impact of many cancer treatments and to reducing cancer deaths. </p>
<p>However, where there are proven screening tests that lead to earlier diagnosis and better outcomes, such as colonoscopy screening for bowel cancer, these are typically unpleasant. They also have associated risks, only screen for one cancer at a time and population uptake is often poor. And for many major tumour types there are currently no effective screening tests.</p>
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Read more:
<a href="https://theconversation.com/can-we-use-a-simple-blood-test-to-detect-cancer-63183">Can we use a simple blood test to detect cancer?</a>
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<p>There are characteristic patterns of mutations and altered proteins that differ among cancer types. So CancerSEEK can not only detect that there is a cancer somewhere in the body but can also suggest where to start looking. </p>
<p>For example, if the pattern suggests a bowel cancer, then a colonoscopy is a logical next step. When blood samples were taken from over 800 apparently healthy controls, less than 1% scored a positive test. This means the test is rarely positive for people who don’t have cancer, thereby reducing the problem of overdiagnosis.</p>
<p>Overall, these results appear to be in stark contrast to previously developed blood-based tests for cancer screening. Currently the only widely used one of is the prostate specific antigen (PSA) test for prostate cancer. This has multiple limitations and some would argue the jury is still out on whether PSA based testing does more good than harm. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/four-reasons-i-wont-have-a-prostate-cancer-blood-test-35085">Four reasons I won't have a prostate cancer blood test</a>
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<h2>What next?</h2>
<p>Large trials are now underway in the US, with CancerSEEK testing being offered to thousands of healthy people. Cancer incidence and outcomes in these people will be compared to a control group who do not have testing. Study results will be available in the next three to five years.</p><img src="https://counter.theconversation.com/content/90221/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Gibbs received funding from NHMRC that supported some of the research described. </span></em></p>There are currently few effective and non-invasive methods to screen for early stages of cancer. But scientists have now developed a new blood test that promises to detect eight different cancers.Peter Gibbs, Professor and Laboratory Head, Walter and Eliza Hall InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/864342017-11-29T22:41:33Z2017-11-29T22:41:33ZMovember shavedown: Why you should not get your prostate checked<figure><img src="https://images.theconversation.com/files/192585/original/file-20171031-18689-9w3g2o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Even if they are not treated, only about three per cent of men will die of prostate cancer over their lifetime, most in their 70s or 80s. </span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>As Movember comes to a close, and men flaunt or shave the facial hair they have grown, there is something people should know — prostate cancer screening is ineffective and can do more harm than good.</p>
<p><a href="https://ca.movember.com/">Movember is a global charity</a> that raises money for men’s health. One of its key areas for fundraising and awareness is to advocate for prostate cancer testing with a PSA test.</p>
<p>As a family physician and public health researcher, I am not getting a prostate cancer test: Neither a rectal examination nor a PSA blood test. </p>
<p>As a man of a certain age, I am likely to already have prostate cancer, and I know that suffering and even dying from this cancer is on the list of possible fates that await me. My choice is not because I have my head in the sand. It is because, after studying the evidence, I know that a test will likely not improve my outcome.</p>
<h2>Screening is ineffective</h2>
<p>In recent years, the pressure on men to be screened for prostate cancer has been mounting, with organisations encouraging us to “<a href="http://www.prostatecancer.ca/getmedia/b4ce9069-b818-462b-8e17-7cc7b4ec7df1/471_PSA-Know-Your-Number_IG_HiRes_1.jpg.aspx">know your number</a>.” </p>
<p>“It is only a simple blood test,” after all. </p>
<p>Prostate Canada says that <a href="http://www.prostatecancer.ca/Prostate-Cancer/About-Prostate-Cancer/Statistics">one in seven men will have prostate cancer</a>. With the help of screening and then curative surgical treatment, Movember and Prostate Canada claim that <a href="https://ca.movember.com/mens-health/prostate-cancer">prostate cancer now has a cure rate of over 97 per cent</a>. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/196825/original/file-20171128-28899-12zybl6.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/196825/original/file-20171128-28899-12zybl6.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/196825/original/file-20171128-28899-12zybl6.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/196825/original/file-20171128-28899-12zybl6.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/196825/original/file-20171128-28899-12zybl6.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/196825/original/file-20171128-28899-12zybl6.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/196825/original/file-20171128-28899-12zybl6.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">There is little evidence that PSA screening prevents development of advanced prostate cancer.</span>
<span class="attribution"><span class="source">(Scott White)</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
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<p>Sadly, these claims give a very false impression of the reality. </p>
<p>Prostate cancer is indeed very common, but <a href="http://dx.doi.org/10.1016/j.eururo.2012.02.054">more so in countries that screen a lot, like the United States and Canada</a>. Death rates have less variation. Studies that examined normal men at different ages found <a href="http://dx.doi.org/10.1002/ijc.29538">many men have small amounts of what looks like cancer in their prostate</a>. Over 30 per cent of men in their 60s have some prostate cancer cells, and in their 80s, over half do. But even if they are not treated, <a href="http://dx.doi.org/10.9778/cmajo.20140079">only about three per cent of men will actually die of prostate cancer</a>, and most of that <a href="http://dx.doi.org/10.3322/caac.20026">will occur at the very end of life</a>, in their 70s or 80s. </p>
<p>If we find cancer many years earlier than we would normally, of course the men will survive five years, though they may still die at the same age as they would have without screening. This is called “lead-time bias.” </p>
<p>Since many prostate cancers grow very slowly many men will die of something else before the cancer can affect them. This is called “overdiagnosis:” Identifying disease that will never be important.</p>
<p>The evidence shows that <a href="http://dx.doi.org/10.3322/caac.20026">if we left men alone we would only recognise prostate cancer in perhaps one in 16 men</a>. The cure rate looks high, because we create false alarms and label many men as having cancer that will never affect them.</p>
<p>Screening is not “just a test.” To take this test is to step into a canoe running down a river with wild and unpredictable rapids. Let me explain….</p>
<h2>Tests are hard to interpret</h2>
<p>The PSA test is a laboratory measurement with errors: Both false positive and false negative. The <a href="http://dx.doi.org/10.5489/cuaj.4888">threshold for abnormality is not clear</a>. Different authorities recommend different levels, and many vary with age.</p>
<p>For men who test positive, the first investigation is usually a prostate biopsy — a needle is poked into the prostate gland multiple times to obtain samples of the gland, to be examined under the microscope. This procedure can carry infection into the gland, and <a href="http://dx.doi.org/10.1016/j.eururo.2016.08.004">results in severe infections in one per cent of patients</a>. Sometimes this becomes septicemia (blood poisoning) that damages kidneys and other organs, or kills the man. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/192592/original/file-20171031-18693-1kyznwa.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/192592/original/file-20171031-18693-1kyznwa.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=592&fit=crop&dpr=1 600w, https://images.theconversation.com/files/192592/original/file-20171031-18693-1kyznwa.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=592&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/192592/original/file-20171031-18693-1kyznwa.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=592&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/192592/original/file-20171031-18693-1kyznwa.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=744&fit=crop&dpr=1 754w, https://images.theconversation.com/files/192592/original/file-20171031-18693-1kyznwa.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=744&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/192592/original/file-20171031-18693-1kyznwa.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=744&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A prostate biopsy.</span>
<span class="attribution"><span class="source">(Wikimedia Commons/Cancer Research UK)</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>The biopsy samples are examined under the microscope by pathologists, who try to predict from their appearance whether this collection of cells is likely to go on to kill the man. </p>
<p>This is difficult: Most cell changes that look like cancer do not develop, spread and kill. Prediction is easier for severe changes than for more frequent minor changes. </p>
<p>Treatment is potentially helpful for the few men with severe changes, but for the majority with minor changes it is unclear how best to proceed.</p>
<h2>Incontinence and erectile difficulty</h2>
<p>Treatment varies and can do more harm than good. Some urologists treat all “cancers.” Others follow a newer approach of surveillance, with regular re-testing, and possibly a repeat biopsy. Thus a well man can be converted into a “possible cancer” patient, getting regular tests, and being reminded that he might have a developing cancer. It is not surprising that many such men decide to have surgery, just to get the gland out, and save the anxiety.</p>
<p>Having surgery to remove the prostate is not a benign process. As with any operation there is a risk of complications. <a href="https://www.uspreventiveservicestaskforce.org/Page/Document/draft-evidence-review/prostate-cancer-screening1">Some men will get infections, blood clots and a few will die</a>. </p>
<p>After recovery, many men have urinary incontinence and erectile difficulty. It is hard to know the actual rates since measuring these is difficult: How much dribbling of urine, or how many embarrassing episodes of urgency should be counted to decide it is important? Measurement of all these outcomes is usually only published by the best centres that are willing to publicly describe their outcomes. There is <a href="http://www.systemperformance.ca/report/prostate-cancer-control-in-canada-a-system-performance-spotlight-report/">wide variation across Canada</a>: It appears that results are worse for many centres.</p>
<p>Everyone assumes that having the operation for early cancer will cure it. </p>
<p>Yes, it does, for a small proportion of men. The few trials available comparing surgery with not treating prostate cancer <a href="https://doi.org/10.1056/NEJMoa1606220">show a very small benefit for surgery</a>. If you had an early cancer that would not develop, then the surgery cured you. (But you never needed the cure.) </p>
<p>On the other hand, most men with severe cancer still die despite screening and treatment.</p>
<h2>Inadequate evidence on screening benefits</h2>
<p>The enthusiasts for PSA screening assert that they are preventing development of advanced prostate cancer. I wish that were true. </p>
<p>Their evidence comes from one project conducted in Europe, where seven centres started running trials on thousands of men aged 55 to 70 years, but <a href="https://doi.org/10.1016/S0140-6736(14)60525-0">only two of the centres showed clear positive results</a>. Even in the trials with positive results, the chance of benefit was small. To prevent each single death from prostate cancer, they had to invite around 800 men. Harms occurred, as over-diagnosis rates were high. And, after 13 years of follow-up, for one less death, six men still died of the disease. So screening does not prevent death from prostate cancer, only reduces it slightly. </p>
<p>Criticism of the trials has also pointed out that these results could be due to the screened men being treated at highly skilled centres, that offered more modern drug treatment. If so, men should simply wait until they get cancer, then obtain high-quality treatment. This choice gives a slightly higher risk of cancer spread, but reduces the chance of over-diagnosis followed by unnecessary treatment. </p>
<p>After the European trial results were published, most evidence-based medical groups including the Canadian Task Force on Preventive Health Care decided that men are more likely to experience harm than benefit from screening. So they <a href="http://dx.doi.org/10.1503/cmaj.140703">warned against screening</a>. Their evidence is summarized in <a href="https://canadiantaskforce.ca/tools-resources/infographic/">decision aids to assist men to understand the risks and benefits</a>. </p>
<h2>What do urology specialists say?</h2>
<p>Urology Associations have a conflict: their members see men dying miserably from the disease, and naturally want to do everything to stop it. However, they too became more cautious after seeing the trial outcome, and now <a href="http://dx.doi.org/10.5489/cuaj.4888">recommend that men should be informed of the risks before they start down the screening pathway</a>. </p>
<p>The American Urology Association recommends that men under age 55 should not be screened. The <a href="https://www.cua.org/en">Canadian Urology Association</a> was in agreement, but recently <a href="http://dx.doi.org/10.5489/cuaj.4888">lowered the age to 50 years</a>, except in special cases of strong family history, where the risk of cancer is higher. It is not clear how well their members follow these recommendations. Many clearly do not. </p>
<p>The <a href="http://www.prostatecancercentre.ca/manvan">Calgary “Man Van”</a> — a mobile men’s health clinic offering PSA testing — recommends testing from the age of 40 and does not inform men of the uncertainties involved. This organisation is advised by urologists, who clearly do not follow their organisation’s policies. The <a href="https://ca.movember.com/mens-health/prostate-cancer">Movember movement says age 50, and 45 for those at high risk</a>. </p>
<p>And for men with higher risk, because of a strong family history, or slightly raised risk because of African ancestry — we have no clear evidence. We simply do not know whether screening is more or less effective among these men, nor whether their risk starts earlier than other men. </p>
<h2>Marketing behind PSA tests.</h2>
<p>The PSA test has been directly marketed to men. The sponsors are not always clear, but appear to be the manufacturers of the tests, and others who profit from screening. They include <a href="http://www.prostatecancer.ca/About-Us/Corporate-Supporters">companies that make surgical equipment and drugs used to treat cancer, and supermarkets that sell incontinence products</a>. For these generous donors, the more men who are diagnosed, the more product they sell.</p>
<p>Prostate screening organisations have also persuaded many men of goodwill that this is a life-saving activity. And they have enlisted other donors who believe in the movement, often after having had a “cancer” removed, persuaded they have been cured by surgery. </p>
<p>It is difficult to tell such survivors that they likely had unnecessary surgery that caused the risks and complications, while most who have severe cancer still die despite the treatment.</p>
<h2>Better ways to improve men’s health</h2>
<p>Men die on average six years earlier than women. For young men, injury and violence including road accidents are the commonest cause, often fuelled by alcohol. In midlife up to age 75, cancer is the most important cause of death. After that, cardiovascular disease dominates. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/196816/original/file-20171128-28917-1arsep0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/196816/original/file-20171128-28917-1arsep0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/196816/original/file-20171128-28917-1arsep0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/196816/original/file-20171128-28917-1arsep0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/196816/original/file-20171128-28917-1arsep0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/196816/original/file-20171128-28917-1arsep0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/196816/original/file-20171128-28917-1arsep0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Lifestyle adaptations such as healthy eating and doing regular exercise may serve most men better than a prostate cancer test.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>But <a href="http://www.cancer.ca/en/cancer-information/cancer-101/canadian-cancer-statistics-publication/?region=on&gclid=EAIaIQobChMI9cnn3fK-1wIVU0sNCh36fwAIEAAYASABEgJUtvD_BwE">prostate cancer only comprises 20 per cent of the cancers</a>. Lung cancer is still the most common fatal cancer in men, largely caused by smoking. Indeed <a href="https://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdf">more than half of all smokers die of smoking-caused disease</a>, so for them, other causes barely matter.</p>
<p>Many men <a href="http://www.statcan.gc.ca/pub/82-624-x/2014001/article/11922-eng.pdf">are obese, have high blood pressure and diabetes</a> (which are <a href="http://www.phac-aspc.gc.ca/publicat/2009/ndssdic-snsddac-09/pdf/report-2009-eng.pdf">often poorly controlled</a>). All these improve with behavioural change: men need to quit smoking, minimize alcohol, eat healthy food and take regular exercise. Even a small increase in activity, such as walking regularly, will <a href="http://dx.doi.org/10.1186/s12889-016-3021-1%20**https://www.mayoclinic.org/healthy-lifestyle/fitness/in-depth/aerobic-exercise/art-20045541?p=1**">make a substantial difference to the effect of these diseases and lower the risk of death</a>. It also helps people feel better.</p>
<p>Thus rather than encouraging “a simple blood test,” it is far better for men to encourage one another to change behaviours. This is likely to have far more value — with fewer negative effects — than doing PSA tests.</p><img src="https://counter.theconversation.com/content/86434/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>James Dickinson was a member of the Canadian Task Force on Preventive Health Care, which is a committee of independent volunteers, with secretariat and meeting costs supported by funding from the Public Health Agency of Canada. </span></em></p>A family physician and public health researcher explains why he isn’t getting a prostate cancer test in Movember or at any time in the near future.James Dickinson, Professor of Family Medicine, University of CalgaryLicensed as Creative Commons – attribution, no derivatives.