tag:theconversation.com,2011:/us/topics/psa-3568/articlesPSA – The Conversation2023-11-08T13:36:27Ztag:theconversation.com,2011:article/2157802023-11-08T13:36:27Z2023-11-08T13:36:27ZNew anti-violence PSA may hit home, but change depends on follow-up and other factors<figure><img src="https://images.theconversation.com/files/557144/original/file-20231101-21-lji227.png?ixlib=rb-1.1.0&rect=132%2C45%2C3598%2C2092&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">"Goodbye" is the name of a new PSA that seeks to show the impact of gun violence.</span> <span class="attribution"><a class="source" href="https://vimeo.com/862137854/928ba36c0e?share=copy">Maryland U.S. Attorney's Office</a></span></figcaption></figure><p><em>When Erek L. Barron, <a href="https://www.justice.gov/usao-md/meet-us-attorney">U.S. attorney for the District of Maryland</a>, premiered a <a href="https://vimeo.com/862137854/928ba36c0e?share=copy">60-second video</a> that seeks to show how gun violence devastates families, he said his goal was to create an <a href="https://www.washingtonpost.com/dc-md-va/2023/09/28/end-gun-violence-psa-erek-barron/">innovative public service announcement</a> that would help “turn around violent crime and improve safety in our neighborhoods.”</em></p>
<p><em>Titled “Goodbye,” the <a href="https://vimeo.com/862137854/928ba36c0e?share=cop">video PSA</a> starts with a high school girl, Tasha, getting a surprise visit from the ghost of her brother, “T,” who tells his sister that he won’t be home and that she is now in charge.</em></p>
<p><em>After T disappears, Tasha learns from law enforcement and Barron that her older brother has been shot and killed.</em> </p>
<p><em>While the PSA – released in September 2023 – is heartbreaking, a critical question remains: Will it work? To answer that question, The Conversation reached out to three communication scholars for their perspectives on the effectiveness of PSAs.</em> </p>
<p></p><hr><p></p>
<h2>Jessica Gall Myrick, professor of health communication</h2>
<p><strong>Penn State University</strong></p>
<p>While PSAs can prompt people to talk about a particular topic and keep it front of mind, using PSAs to persuade people to actually <a href="https://doi.org/10.1016/S0140-6736(10)60809-4">change behavior</a> is more difficult.</p>
<p>Some people simply <a href="https://doi.org/10.4278/0890-1171-12.1.38">are not ready to change</a>. They are at what researchers call the “precontemplative stage.” For such people, a PSA can be more persuasive if it just gets them to think about the topic. One strategy to achieve this end is to <a href="https://oxfordre.com/communication/display/10.1093/acrefore/9780190228613.001.0001/acrefore-9780190228613-e-324">appeal to people’s emotions</a>.</p>
<p>However, just provoking an emotional response will not necessarily lead to a change in behavior. If audiences are overwhelmed with <a href="https://doi.org/10.1080/17437199.2017.1415767">fear</a> or anger, they <a href="https://doi.org/10.4135/9781452218410">often reject the message</a> or discredit its source.</p>
<p>When encouraging audiences to emotionally invest in a topic, too much of any one negative emotion may backfire, while not enough will leave them uninterested, perhaps believing the topic is not very important.</p>
<p>Research suggests that many audiences often respond more favorably to <a href="https://doi.org/10.1080/10410236.2017.1422847">messages that offer some hope, at least by the end</a>. Hope is an important emotion because it can boost our confidence in our ability to handle the threat discussed in the PSA.</p>
<p>In the case of a PSA like “Goodbye,” the sadness or sympathy evoked by showing the grief of the little sister may not immediately change anyone’s policy position or attitude about guns. However, it is memorable – it has the potential to keep people thinking about the issue of gun violence.</p>
<p>“Goodbye” also makes the impact of gun violence more concrete – it feels less abstract than a news story filled with statistics about injuries or deaths. </p>
<p>When stories <a href="https://ijoc.org/index.php/ijoc/article/view/4824">evoke feelings of empathy and identification</a> with the people directly affected by a social issue, they can help audiences to start to think more, and more often, about the issue’s effects on both themselves and on society more broadly, even if they do not instantly change behavior. </p>
<h2>Holli H. Seitz, professor of communication</h2>
<p><strong>Mississippi State University</strong></p>
<p>When they work, media campaigns – which often include PSAs – can have <a href="https://doi.org/10.1080/10810730490271548">small beneficial effects</a> on <a href="https://doi.org/10.1080/10810730.2015.1095820">people’s behavior and knowledge</a>. However, sometimes PSAs have unintended effects or even harmful effects on behavior. In such cases, the effects are called “<a href="https://doi.org/10.1111/j.1460-2466.2007.00344.x">boomerang effects</a>” because they go in an unexpected direction.</p>
<p>Case in point: From 1998 to 2004, Congress appropriated over <a href="https://www.gao.gov/products/gao-06-818">US$1.2 billion for the National Youth Anti-Drug Media Campaign</a>. However, an evaluation found that the media campaign <a href="https://doi.org/10.2105/AJPH.2007.125849">failed to have favorable effects</a> and may have even <a href="https://www.gao.gov/products/gao-06-818">promoted the perception that drug use among others was normal</a>.</p>
<p>Even in cases where the message of a PSA is effective, there are other factors to consider. </p>
<p>For one, a lot of PSA research was conducted before the rise of social media. The changing media landscape may make it more difficult for PSAs to wrestle people’s attention away from whatever else they’re viewing.</p>
<p>Secondly, PSA creators don’t always do enough to ensure that their PSAs reach their intended audience. Getting a PSA into the media platforms that the target audience uses – and showing it frequently – is <a href="https://doi.org/10.1080/15245000214135">key to see effects</a>. The limited effects of past programs, such as the <a href="https://doi.org/10.2105/AJPH.85.2.183">Community Intervention Trial for Smoking Cessation</a>, <a href="https://doi.org/10.1080/15245000214135">may be attributable to a lack of sufficient exposure</a> to key messages. </p>
<p>To increase the effectiveness of PSAs, we can look to communication research for guidance. <a href="https://doi.org/10.1080/10810730500461059">Communication scholar Seth Noar</a> says that campaigns are more likely to be effective when campaign creators conduct research with the intended audience to understand the behavior they hope to change and pretest messages for effectiveness. For example, a <a href="https://doi.org/10.1186/s12961-019-0430-5">campaign to encourage people in Victoria, Australia, to reserve ambulances for emergencies</a> used audience research to inform their campaign development. An <a href="https://doi.org/10.1186/s12961-019-0430-5">evaluation</a> of that campaign showed desirable effects on public attitudes toward the appropriate use of ambulances.</p>
<h2>Sara C. Doan, assistant professor of experience architecture</h2>
<p><strong>Michigan State University</strong></p>
<p>I argue that telling a relatable story makes people want to act. By avoiding the lectures, such as <a href="https://www.scientificamerican.com/article/why-just-say-no-doesnt-work/">Nancy Reagan’s “Just Say No”</a> anti-drug campaign, and the ironic pictures and quotes from New York City’s <a href="https://www.cbsnews.com/news/new-york-citys-new-teen-pregnancy-psas-use-crying-babies-to-send-message/">posters of crying babies to prevent teen pregnancy</a>, Maryland’s PSA invokes a real situation: how families of gun violence victims deal with losing a family member.</p>
<p>This story allows people to bring their own knowledge, experience and social connections to the <a href="https://www.kff.org/mental-health/issue-brief/the-impact-of-gun-violence-on-children-and-adolescents/#:%7E:text=Gun%20violence%20may%20also%20lead,deaths%20among%20children%20and%20adolescents">problem of gun violence</a>, making people want to act. T tells his younger sister, “You’re in charge right now, Tasha… Just feed my birds for me, alright?” This dialogue feels genuine, without the cheesiness that made people <a href="https://doi.org/10.2105/AJPH.92.2.238">joke about previous anti-drug PSAs</a>.</p>
<p>People <a href="https://pubmed.ncbi.nlm.nih.gov/23448568/">respond better to real images and situations</a> in PSAs, especially when the topic is unpleasant. The “Goodbye” PSA shocked me but doesn’t rely on shock value.</p>
<p>I believe a call to action – whether by a local government, nongovernment organization, or a group of citizen activists – that <a href="https://doi.org/10.1111/bjhp.12310">shows how people’s actions will matter</a> would make the PSA’s message more powerful. </p>
<p>Actions also need to follow a PSA to change people’s behavior.</p>
<p>For example, the <a href="https://www.nhtsa.gov/campaign/click-it-or-ticket">National Highway Traffic Safety Administration’s</a> campaign “Click It or Ticket” – <a href="https://ncvisionzero.org/wp-content/uploads/2016/08/ciot-history.pdf">combined with traffic enforcement</a> begun in the 1990s and still ongoing – has helped raise rates of seat belt use by <a href="https://www.nhtsa.gov/campaign/click-it-or-ticket">8% between 2009 and 2022</a>. </p>
<p>The horrors of gun violence should not be made into a snappy slogan, which, thankfully, Maryland’s PSA avoids. I argue that giving people a concrete action to take – and <a href="https://www.baltimoresun.com/news/crime/bs-md-ci-cr-baltimore-national-intiative-to-reduce-gun-homicides-20230223-hc3fw56hcjfj3cnq6f62vajyd4-story.html">empowering communities to act</a> through funding and support for on-the-ground efforts – would make PSAs more effective.</p><img src="https://counter.theconversation.com/content/215780/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Holli H. Seitz receives funding from the Extension Foundation, the National Science Foundation, and the U.S. Department of Agriculture. She has previously received funding from the Substance Abuse and Mental Health Services Administration. Seitz received her PhD from the Annenberg School for Communication at the University of Pennsylvania where she worked with Dr. Robert Hornik whose research is cited in this article.</span></em></p><p class="fine-print"><em><span>Jessica Gall Myrick receives funding from the National Institutes of Health and the National Science Foundation.</span></em></p><p class="fine-print"><em><span>Sara C. Doan 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>The US attorney for the District of Maryland recently released a PSA to help stem the tide of violence in the state. But will it work?Holli H. Seitz, Associate Professor of Communication, Mississippi State UniversityJessica Myrick, Professor of Media Studies, Penn StateSara C. Doan, Assistant Professor of Experience Architecture, Michigan State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2133592023-09-18T20:03:42Z2023-09-18T20:03:42ZTests that diagnose diseases are less reliable than you’d expect. Here’s why<figure><img src="https://images.theconversation.com/files/548709/original/file-20230918-27-xhsztq.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C3583%2C2376&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/OZcQIhidMTw">CDC / Unsplash</a></span></figcaption></figure><p>You feel unwell, and visit your doctor. They ask some questions and take some blood for testing; a few days later they call to say you have been diagnosed with a disease.</p>
<p>What are the chances you <em>actually have</em> the disease? For some common diagnostic tests, the answer is surprisingly low.</p>
<p>Few medical tests are 100% accurate. Part of the reason is that people are inherently variable, but many tests are also built on limited or biased samples of patients – and our own work has shown researchers may <a href="https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-023-03048-6">deliberately exaggerate</a> the effectiveness of new tests.</p>
<p>None of this means we should stop trusting diagnostic tests, but a better understanding of their strengths and weaknesses is essential if we want to use them wisely. </p>
<h2>People are variable</h2>
<p>An example of a widely used imperfect test is prostate-specific antigen (PSA) screening, which measures the level of a particular protein in the blood as an indicator of prostate cancer. </p>
<p>The test catches an estimated 93% of cancers – but it has a very high false positive rate, as around 80% of men with a positive result do not actually have cancer. For those in the 80%, the result <a href="https://theconversation.com/prostate-cancer-testing-has-the-bubble-burst-82260">creates unnecessary stress</a> and likely further testing including painful biopsies.</p>
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Read more:
<a href="https://theconversation.com/prostate-cancer-testing-has-the-bubble-burst-82260">Prostate cancer testing: has the bubble burst?</a>
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<p>Rapid antigen tests for COVID-19 are another widely used imperfect test. A <a href="https://www.cochrane.org/CD013705/INFECTN_how-accurate-are-rapid-antigen-tests-diagnosing-covid-19">review of these tests</a> found that, of people without symptoms but with a positive test result, only 52% actually had COVID. </p>
<p>Among people with COVID symptoms and a positive result, the accuracy of the tests rose to 89%. This shows how a test’s performance cannot be summarised by a single number and depends on individual context.</p>
<p>Why aren’t diagnostic tests perfect? One key reason is that people are variable. A high temperature for you, for example, might be perfectly normal for someone else. For blood tests, many extraneous factors can influence the results, such as the time of day or how recently you have eaten.</p>
<p>Even the ubiquitous blood pressure test <a href="https://www.ama-assn.org/delivering-care/hypertension/4-big-ways-bp-measurement-goes-wrong-and-how-tackle-them">can be inaccurate</a>. Results can vary depending on whether the cuff is a good fit for your arm, if you have your legs crossed, and if you’re talking when the test is done. </p>
<h2>Small samples and statistical skullduggery</h2>
<p>There’s an enormous amount of research on new diagnostic models. New models frequently make the headlines as “medical breakthroughs”, such as how your <a href="https://www.jpost.com/health-and-science/handwriting-assessment-can-be-used-for-early-detection-of-parkinsons-disease-325798">handwriting could detect Parkinson’s disease</a>, how your pharmacy loyalty card could <a href="https://www.theguardian.com/society/2023/jan/26/loyalty-card-data-could-help-spot-ovarian-cancer-cases-sooner">detect ovarian cancer earlier</a>, or how <a href="https://www.abdn.ac.uk/news/4602/">eye movements could detect schizophrenia</a>.</p>
<p>But living up to the headlines is often a different story.</p>
<p>Many diagnostic models are developed based on small sample sizes. <a href="https://www.bmj.com/content/332/7550/1127.long">A review</a> found half of diagnostic studies used just over 100 patients. It is hard to get a true picture of the accuracy of a diagnostic test from such small samples. </p>
<p>For accurate results, the patients who use the test should be similar to those who were used to develop the test. For example, the widely used Framingham Risk Score for identifying people at high risk of heart disease was developed in the United States and is known to <a href="https://pubmed.ncbi.nlm.nih.gov/28749178/">perform poorly</a> in Aboriginal and Torres Strait Islander people. </p>
<p>Similar disparities in accuracy have been found for “polygenic risk scores”. These combine information on thousands of genes to predict disease risk, but were developed in European populations and <a href="https://www.nature.com/articles/s41588-019-0379-x">perform poorly in non-European populations</a>. </p>
<p>Recently, we identified another important problem: researchers have exaggerated <a href="https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-023-03048-6">the accuracy of some models</a> to gain journal publications. </p>
<p>There are many ways to exaggerate the performance of a test, such as dropping hard-to-predict patients from the sample. Some tests are also not truly predictive, as they include information from the future, such as a <a href="https://www.statnews.com/2021/09/27/epic-sepsis-algorithm-antibiotics-model/">predictive model of infection</a> that includes whether the patient had been prescribed antibiotics.</p>
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<strong>
Read more:
<a href="https://theconversation.com/elizabeth-holmes-theranos-scandal-has-more-to-it-than-just-toxic-silicon-valley-culture-114102">Elizabeth Holmes: Theranos scandal has more to it than just toxic Silicon Valley culture</a>
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<p>Perhaps the most extreme example of exaggerating the power of a diagnostic test was the <a href="https://theconversation.com/elizabeth-holmes-theranos-scandal-has-more-to-it-than-just-toxic-silicon-valley-culture-114102">Theranos scandal</a>, in which a finger-prick blood test supposed to diagnose multiple health conditions attracted hundreds of millions of dollars from investors. This was too good to be true – and the mastermind has now been convicted of fraud. </p>
<h2>Big data can’t make tests perfect</h2>
<p>In the era of precision medicine and big data, it seems appealing to combine tens or hundreds of pieces of information about a patient – perhaps using machine learning or artificial intelligence – to provide highly accurate predictions. However, the promise is so far outstripping the reality. </p>
<p>One <a href="https://osf.io/preprints/4txc6/">study</a> estimated 80,000 new prediction models were published between 1995 and 2020. That’s around 250 new models every month. </p>
<p>Are these models transforming healthcare? We see no sign of it – and if they really were having a big impact, surely we wouldn’t need such a steady stream of new models. </p>
<p>For many diseases there are data problems that no amount of sophisticated modelling can fix, such as measurement errors or missing data that make accurate predictions impossible. </p>
<p>Some diseases or illnesses are likely inherently random, and involve complex chains of events which a patient cannot describe and no model could predict. Examples might include injuries or previous illnesses that happened to a patient decades ago, which they cannot recall and are not in their medical notes. </p>
<p>Diagnostic tests will never be perfect. Acknowledging their imperfections will enable doctors and their patients to have an informed discussion about what a result means – and most importantly, what to do next.</p><img src="https://counter.theconversation.com/content/213359/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>Many diagnostic tests are far from 100% accurate – and even in the era of big data and machine learning, they never will be.Adrian Barnett, Professor of Statistics, Queensland University of TechnologyNicole White, Senior Research Fellow - Statistics, Queensland University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1719382021-11-29T13:35:24Z2021-11-29T13:35:24ZWhy we’re using filmmaking to encourage vaccination by Black and Latino Angelenos<figure><img src="https://images.theconversation.com/files/433265/original/file-20211122-19-cxfip1.JPG?ixlib=rb-1.1.0&rect=0%2C0%2C2250%2C1331&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Strong narratives can help sway opinions.</span> <span class="attribution"><span class="source">Jeremy Kagan</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>People have recognized the power of storytelling for <a href="https://www.meetcortex.com/blog/the-history-of-storytelling-in-10-minutes">thousands of years</a>. The Bible relies on parables like the <a href="https://www.gotquestions.org/parable-prodigal-son.html">prodigal son</a> because stories successfully convey the underlying message in a memorable way that’s easy to pass along to future generations.</p>
<p>But when public health leaders and medical professionals need to communicate crucial, potentially life-saving health information, they can fail to harness the strength of storytelling.</p>
<p>That’s why we, a <a href="http://www.cmml-usc.org">filmmaking professor</a>, a <a href="https://scholar.google.com/citations?user=wRcItGIAAAAJ&hl=en&oi=ao">health communications scholar</a> and a <a href="https://scholar.google.com/citations?hl=en&user=IxA7uIUAAAAJ">public health professor</a> specializing in community outreach, wanted to see if we could help once COVID-19 vaccines became widely available. We stepped up after seeing that <a href="https://doi.org/10.1016/j.pmedr.2021.101544">the vaccination rates of Latino and Black residents</a> of Los Angeles were roughly 20 percentage points lower than for white Angelenos. By May 1, 2021, 60% of white Angelenos had received at least one dose of the vaccine, compared to 42% for Latinos and 36% for Black residents.</p>
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<a href="https://images.theconversation.com/files/433196/original/file-20211122-27-1luxf1z.jpg?ixlib=rb-1.1.0&rect=83%2C35%2C3910%2C2203&q=45&auto=format&w=1000&fit=clip"><img alt="A nurse gets ready to give people the Pfizer COVID-19 vaccine." src="https://images.theconversation.com/files/433196/original/file-20211122-27-1luxf1z.jpg?ixlib=rb-1.1.0&rect=83%2C35%2C3910%2C2203&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/433196/original/file-20211122-27-1luxf1z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/433196/original/file-20211122-27-1luxf1z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/433196/original/file-20211122-27-1luxf1z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/433196/original/file-20211122-27-1luxf1z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/433196/original/file-20211122-27-1luxf1z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/433196/original/file-20211122-27-1luxf1z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&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">Health care workers set up a COVID-19 vaccination clinic at a community event in a predominately Latino neighborhood in Los Angeles in August 2021.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/healthcare-workers-set-up-a-covid-19-vaccination-clinic-at-news-photo/1234625641">Robyn Beck/AFP via Getty Images</a></span>
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<h2>6 key points</h2>
<p>We assembled two separate film crews, comprised of Latino and Black cinematic arts graduate students attending the School of Cinematic Arts at the University of Southern California, to make two short films to counter vaccine hesitancy in both communities. The crews wrote scripts countering the most prevalent COVID-19 myths and then went into production on real locations in Los Angeles.</p>
<p>We worked on this project with <a href="https://vaccinatela.info/">VaccinateLA</a>, a joint effort between the University of Southern California, multiple hospitals and dozens of community organizations.</p>
<p>The Latino crew’s 6-minute film, “<a href="https://vimeo.com/574033678/adba2874da">Of Reasons and Rumors</a>,” relays the story of a tight-knit Latino family in East LA divided by disagreement over the importance and safety of vaccination against COVID-19. Through the characters, viewers confront what they would do if being unvaccinated kept them away from their loved ones. We also produced another version of this <a href="https://vimeo.com/574041865/54a2ea9f28">film in Spanish</a>.</p>
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<figcaption><span class="caption">In the short film ‘Of Reasons and Rumors,’ members of a Latino family discuss their concerns about the importance and safety of COVID-19 vaccines.</span></figcaption>
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<p>The Black crew’s 6-minute film, “<a href="https://vimeo.com/574495934/f619a5b3b7">Happy Birthday, Granny</a>,” revolves around an African American family in South LA. The family is celebrating their grandmother’s 80th birthday when an argument leads to a volatile discussion about the truth about the development and safety of COVID-19 vaccines.</p>
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<figcaption><span class="caption">During the short film ‘Happy Birthday, Granny,’ an African American family argument leads to a myth-busting discussion about COVID-19 vaccine safety.</span></figcaption>
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<p>Research about narrative-driven films that are made to motivate behavioral changes, known as <a href="https://www.communicationtheory.org/entertainment-education/">entertainment-education communication theory</a>, suggests that facts inform while stories transform. We believed that making these stories effective would rely on two things.</p>
<p>First, the narrative needed to be sufficiently engaging to <a href="https://doi.org/10.1037/0022-3514.79.5.701">transport viewers into the narrative world</a> so that they don’t notice, and possibly argue against, the vaccine-related information being conveyed. Second, it was important to use characters with whom <a href="https://doi.org/10.1111/j.1468-2885.2008.00328.x">viewers can identify</a>. That’s why the casts for both films didn’t include any celebrities.</p>
<p>The films, completed in July 2021, make the following six key points:</p>
<ol>
<li><p>The vaccines made use of <a href="https://apnews.com/article/years-research-groundwork-covid-19-shots-f204192f07cfcc3503dc9c7687ae6269">research underway for more than 20 years</a>.</p></li>
<li><p>The vaccines <a href="https://theconversation.com/covid-19-could-cause-male-infertility-and-sexual-dysfunction-but-vaccines-do-not-164139">don’t affect fertility</a>.</p></li>
<li><p>Except for the Johnson & Johnson vaccine, <a href="https://www.cdc.gov/coronavirus/2019-ncov/vaccines/second-shot.html">at least two doses are required</a>.</p></li>
<li><p>Too few people have been vaccinated to <a href="https://theconversation.com/what-is-herd-immunity-a-public-health-expert-and-a-medical-laboratory-scientist-explain-170520">end the COVID-19 pandemic</a>.</p></li>
<li><p>People who have <a href="https://www.cdc.gov/mmwr/volumes/70/wr/mm7044e1.htm">gotten COVID-19 still need to be vaccinated</a> to be protected from new variants of the coronavirus.</p></li>
<li><p>The vaccines are <a href="https://www.cdc.gov/vaccines/covid-19/reporting/vaccinefinder/about.html">easily accessible</a> through <a href="http://publichealth.lacounty.gov/acd/ncorona2019/vaccine/hcwsignup/">pharmacies, clinics and mobile vans</a>.</p></li>
</ol>
<h2>Piquing interest in getting vaccinated</h2>
<p>We wanted to know whether these films would resonate elsewhere. Before distributing the films more broadly, we first showed them to a national sample of 600 unvaccinated Latinos and African Americans who took part in a forthcoming online study. Some watched films that featured characters of their own ethnicity, and others saw the film featuring the other ethnicity.</p>
<p>Although viewers who saw an ethnically matched film identified more with the characters and showed the greatest increase in their intent to get vaccinated in the next 30 days, viewers of either film could correctly reject the six myths both films seek to debunk. </p>
<p>Based on our results, we believe that both films could also help persuade Black and Latino people outside Los Angeles who haven’t yet gotten vaccinated against COVID-19 to do that.</p>
<p>The <a href="https://www.kff.org/coronavirus-covid-19/issue-brief/latest-data-on-covid-19-vaccinations-by-race-ethnicity/">disparities in vaccination rates</a> for Latinos and <a href="https://theconversation.com/whats-not-being-said-about-why-african-americans-need-to-take-the-covid-19-vaccine-152323">Black Americans</a> relative to whites have persisted, while also narrowing both nationally and locally. In LA County, 75% of white Angelenos were <a href="http://publichealth.lacounty.gov/media/coronavirus/vaccine/vaccine-dashboard.htm#ethnicitybody">vaccinated as of Nov. 11, 2021</a>, versus 66% for Latinos and 58% for African Americans.</p>
<p>[<em>Get the best of The Conversation, every weekend.</em> <a href="https://memberservices.theconversation.com/newsletters/?source=inline-weeklybest">Sign up for our weekly newsletter</a>.]</p>
<p>We are following up with a third film, depicting a multiethnic community. It will encourage parents to have their children vaccinated. Early surveys indicate that many parents are <a href="https://khn.org/news/article/covid-vaccination-teens-parents-proving-tough-sell/">reluctant to take this important step</a>, even as shots for <a href="https://www.cdc.gov/vaccines/covid-19/planning/children.html">kids 5 and up</a> are being rolled out.</p>
<p><em><a href="https://annenberg.usc.edu/communication/communication-phd/doctoral-students/ashley-phelps">Ashley Phelps</a>, a University of Southern California doctoral candidate researching vaccine hesitancy, coordinated the COVID-19 protocols for the filmmaking.</em></p><img src="https://counter.theconversation.com/content/171938/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jeremy Kagan participated pro bono as the filmmaker on projects mentioned in this article that have been funded by the National Institutes of Health and the VaccinateLA partnership.</span></em></p><p class="fine-print"><em><span>Lourdes Baezconde-Garbanati received funds from the W.M. Keck Foundation at the Keck School of Medicine of USC as Co-Director and Co-PI with Michele Kipke of VaccinateLA. She also received funds from the National Alliance for Hispanic Health through a grant from the Health Research Services Administration (HRSA) for her COVID-19 work.</span></em></p><p class="fine-print"><em><span>Sheila Murphy has received funding from the National Institutes of Health for her work on narrative persuasion and the VaccinateLA partnership.</span></em></p>Two film crews comprised of Latino and Black cinematic arts graduate students made short films to counter vaccine fears in both communities.Jeremy Kagan, Professor of Film & Television Production, School of Cinematic Arts, University of Southern CaliforniaLourdes Baezconde-Garbanati, Professor of Population and Public Health Sciences; Associate Dean for Community Initiatives; Associate Director for Community Outreach and Engagement, University of Southern CaliforniaSheila Murphy, Professor of Communication , USC Annenberg School for Communication and JournalismLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1538652021-01-28T13:31:04Z2021-01-28T13:31:04ZWhy using fear to promote COVID-19 vaccination and mask wearing could backfire<figure><img src="https://images.theconversation.com/files/380794/original/file-20210127-17-fd7lz6.jpg?ixlib=rb-1.1.0&rect=622%2C808%2C2856%2C1712&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Images of death have been used as a scare tactic in public health campaigns for years.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/relatives-of-neide-rodrigues-who-died-of-the-coronavirus-news-photo/1212206095">Buda Mendes/Getty Images</a></span></figcaption></figure><p>You probably still remember public service ads that scared you: The <a href="https://www.youtube.com/watch?v=wAaGbsHBacE">cigarette smoker</a> with throat cancer. The <a href="https://www.youtube.com/watch?v=262r7Wuut2A">victims of a drunk driver</a>. The guy who <a href="http://publications.gc.ca/collection_2007/hcc-ccs/H174-3-2006E.pdf">neglected his cholesterol</a> lying in a morgue with a toe tag.</p>
<p>With new, highly transmissible variants of SARS-CoV-2 now spreading, some health professionals have started calling for the use of similar <a href="https://www.nytimes.com/2020/12/07/opinion/covid-public-health-messaging.html">fear-based strategies</a> to persuade people to follow social distancing rules and <a href="https://news.yahoo.com/laurie-garrett-terrified-covid-death-234014915.html">get vaccinated</a>. </p>
<p>There is <a href="http://doi.org/10.1037/a0039729">compelling evidence</a> that fear can change behavior, and there have been ethical arguments that <a href="https://www.oxfordhandbooks.com/view/10.1093/oxfordhb/9780190243470.001.0001/oxfordhb-9780190243470-e-25">using fear can be justified</a>, particularly when threats are severe. As public health professors with <a href="https://scholar.google.com/citations?user=k5_VseQAAAAJ&hl=en">expertise in history</a> and <a href="https://www.publichealth.columbia.edu/people/our-faculty/rb8">ethics</a>, we have been open in some situations to using fear in ways that help individuals understand the gravity of a crisis without creating stigma. </p>
<p>But while the pandemic stakes might justify using hard-hitting strategies, the nation’s social and political context right now might cause it to backfire.</p>
<h2>Fear as a strategy has waxed and waned</h2>
<p>Fear can be a <a href="http://doi.org/10.1037/a0039729">powerful motivator</a>, and it can create <a href="https://hms.harvard.edu/magazine/science-emotion/chill-fear">strong, lasting memories</a>. Public health officials’ willingness to use it to help change behavior in public health campaigns has waxed and waned for more than a century.</p>
<p>From the late 19th century into the early 1920s, <a href="http://doi.org/10.2105/AJPH.2018.304516">public health campaigns commonly sought to stir fear</a>. Common tropes included flies menacing babies, immigrants represented as a microbial pestilence at the gates of the country, voluptuous female bodies with barely concealed <a href="https://www.good.is/slideshows/the-militarys-graphic-design-war-on-venereal-disease?rebelltitem=1#rebelltitem1">skeletal faces</a> who threatened to weaken a generation of troops with syphilis. The key theme was using fear to control harm from others.</p>
<figure class="align-left ">
<img alt="Poster from syphilis scare" src="https://images.theconversation.com/files/380780/original/file-20210127-17-cst0bd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/380780/original/file-20210127-17-cst0bd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=916&fit=crop&dpr=1 600w, https://images.theconversation.com/files/380780/original/file-20210127-17-cst0bd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=916&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/380780/original/file-20210127-17-cst0bd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=916&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/380780/original/file-20210127-17-cst0bd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1151&fit=crop&dpr=1 754w, https://images.theconversation.com/files/380780/original/file-20210127-17-cst0bd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1151&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/380780/original/file-20210127-17-cst0bd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1151&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The Works Progress Administration created posters warning of the dangers of syphilis in the 1930s.</span>
<span class="attribution"><a class="source" href="https://www.loc.gov/item/98516349/">Library of Congress</a></span>
</figcaption>
</figure>
<p>Following World War II, <a href="https://books.google.com/books/about/The_Progress_of_Experiment.html?id=j84gdplK7c0C">epidemiological data</a> emerged as the foundation of public health, and use of fear fell out of favor. The primary focus at the time was the rise of chronic “lifestyle” diseases, such as heart disease. Early behavioral research <a href="https://www.scribd.com/document/250546081/Janis-Feshbach-1953">concluded fear backfired.</a> <a href="https://www.scribd.com/document/250546081/Janis-Feshbach-1953">An early, influential study</a>, for example, suggested that when people became anxious about behavior, they might tune out or even engage more in dangerous behaviors, like smoking or drinking, to cope with the anxiety stimulated by fear-based messaging.</p>
<p>But by the 1960s, health officials were trying to change behaviors related to smoking, eating and exercise, and they grappled with the <a href="https://books.google.com/books/about/The_Progress_of_Experiment.html?id=j84gdplK7c0C">limits of data and logic</a> as tools to help the public. They <a href="http://doi.org/10.2105/AJPH.2018.304516">turned again to scare tactics</a> to try to deliver a gut punch. It was not enough to know that some behaviors were deadly. We had to react emotionally.</p>
<p>Although there were concerns about using fear to manipulate people, leading ethicists began to argue that <a href="https://www.oxfordhandbooks.com/view/10.1093/oxfordhb/9780190243470.001.0001/oxfordhb-9780190243470-e-25">it could help people understand what was in their self-interest</a>. A bit of a scare could help cut through the noise created by industries that made fat, sugar and tobacco alluring. It could help make population-level statistics personal. </p>
<figure class="align-right ">
<img alt="Anti-smoking poster." src="https://images.theconversation.com/files/380777/original/file-20210127-21-10md4z6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/380777/original/file-20210127-21-10md4z6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/380777/original/file-20210127-21-10md4z6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/380777/original/file-20210127-21-10md4z6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/380777/original/file-20210127-21-10md4z6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/380777/original/file-20210127-21-10md4z6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/380777/original/file-20210127-21-10md4z6.jpg?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">
<figcaption>
<span class="caption">New York City has run tough anti-smoking campaigns.</span>
<span class="attribution"><span class="source">NYC Health</span></span>
</figcaption>
</figure>
<p><a href="https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2014.301940?journalCode=ajph">Anti-tobacco campaigns</a> were the first to show the devastating toll of smoking. They used graphic images of diseased lungs, of smokers gasping for breath through tracheotomies and eating through tubes, of clogged arteries and failing hearts. <a href="http://www.bridgingthegapresearch.org/research/wakefield2003_jhc/index.html">Those campaigns</a> worked.</p>
<p>And then came AIDS. Fear of the disease was hard to untangle from fear of those who suffered the most: gay men, sex workers, drug users, and the black and brown communities. The challenge was to destigmatize, to promote the human rights of those who only stood to be further marginalized if shunned and shamed. When it came to public health campaigns, human rights advocates argued, <a href="https://www.oxfordhandbooks.com/view/10.1093/oxfordhb/9780190243470.001.0001/oxfordhb-9780190243470-e-25">fear stigmatized and undermined the effort</a>.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/otR8V7rlnjA?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">A Canadian campaign against drunk driving showed the risks to others.</span></figcaption>
</figure>
<p>When obesity became a public health crisis, and youth smoking rates and vaping experimentation were sounding alarm bells, public health campaigns once again adopted fear to try to shatter complacency. Obesity campaigns sought to stir parental dread about youth obesity. <a href="https://www.oxfordhandbooks.com/view/10.1093/oxfordhb/9780190243470.001.0001/oxfordhb-9780190243470-e-25">Evidence of the effectiveness</a> of this fear-based approach mounted.</p>
<h2>Evidence, ethics and politics</h2>
<p>So, why not use fear to drive up vaccination rates and the use of masks, lockdowns and distancing now, at this moment of national fatigue? Why not sear into the national imagination images of makeshift morgues or of people dying alone, intubated in overwhelmed hospitals?</p>
<p>Before we can answer these questions, we must first ask two others: Would fear be ethically acceptable in the context of COVID-19, and would it work?</p>
<p>For people in high-risk groups – those who are older or have underlying conditions that put them at high risk for severe illness or death – the <a href="http://doi.org/10.1037/a0039729">evidence on fear-based appeals</a> suggests that <a href="https://www.ucpress.edu/book/9780520247499/state-of-immunity">hard-hitting campaigns</a> can work. The strongest case for the efficacy of fear-based appeals comes from smoking: Emotional PSAs put out by organizations like the American Cancer Society beginning in the 1960s proved to be a powerful antidote to tobacco sales ads. Anti-tobacco crusaders found in fear a way to appeal to individuals’ self-interests.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/5zWB4dLYChM?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">This CDC campaign used smokers’ stories as a warning.</span></figcaption>
</figure>
<p>At this political moment, however, there are other considerations.</p>
<p>Health officials have faced armed protesters outside their offices and homes. Many people seem to have lost the capacity to <a href="https://theconversation.com/alternative-facts-a-psychiatrists-guide-to-twisted-relationships-to-truth-72469">distinguish truth from falsehood</a>.</p>
<p>By instilling fear that government will go too far and erode civil liberties, some groups developed an effective political tool for overriding rationality in the face of science, even the <a href="https://theconversation.com/cloth-masks-do-protect-the-wearer-breathing-in-less-coronavirus-means-you-get-less-sick-143726">evidence-based recommendations</a> supporting face masks as protection against the coronavirus.</p>
<p>Reliance on fear for public health messaging now could further erode trust in public health officials and scientists at a critical juncture.</p>
<p>The nation desperately needs a strategy that can help break through pandemic denialism and through the politically charged environment, with its threatening and at times hysterical rhetoric that has created opposition to sound public health measures.</p>
<p>Even if ethically warranted, fear-based tactics may be dismissed as just one more example of political manipulation and could carry as much risk as benefit.</p>
<p>Instead, public health officials should boldly urge and, as they have during other crisis periods in the past, emphasize what has been sorely lacking: consistent, credible communication of the science at the national level.</p><img src="https://counter.theconversation.com/content/153865/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amy Lauren Fairchild received funding from the Greenwall Foundation and the National Science Foundation. </span></em></p><p class="fine-print"><em><span>Ronald Bayer received funding from the Greenwall Foundation. . </span></em></p>History holds some lessons about when scaring people to change their behavior works. Two public health experts offer a case for caution right now.Amy Lauren Fairchild, Dean and Professor, College of Public Health, The Ohio State UniversityRonald Bayer, Professor Sociomedical Sciences, Columbia UniversityLicensed 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>
<hr>
<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>
</strong>
</em>
</p>
<hr>
<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>
<hr>
<p>
<em>
<strong>
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>
</strong>
</em>
</p>
<hr>
<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/1202072019-07-19T11:38:09Z2019-07-19T11:38:09ZSmokey (the) Bear is still keeping his watchful eye on America’s forests after 75 years on the job<figure><img src="https://images.theconversation.com/files/284360/original/file-20190716-173351-buexxe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The PSA star, deployed in the wild</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/smokey-bear-warns-forest-fires-ventura-257294035?studio=1">Joseph Sohm/Shutterstock.com </a></span></figcaption></figure><p><a href="https://smokeybear.com/en">Smokey Bear</a> turns 75 on Aug. 9. </p>
<p>The star of the <a href="https://www.adcouncil.org/Impact/Case-Studies/Wildfire-Prevention-2014">longest-running public-service</a> advertising campaign in U.S. history is now big on social media, with Facebook, Flickr, Instagram and Twitter accounts.</p>
<p>Americans are also still sending the imaginary character loads of real mail. The postal service has delivered hundreds of thousands of the bear’s many letters and occasional jars of honey to his own <a href="https://www.usda.gov/media/blog/2014/07/01/letters-smokey-bear-reveal-promise-hope-future">ZIP code: 20252</a>. </p>
<p>Some <a href="https://www.adcouncil.org/Impact/Case-Studies/Wildfire-Prevention-2014">96% of Americans recognized</a> this constant reminder to keep forests safe, according to a survey in 2013, making him about as familiar as Mickey Mouse and Santa Claus.</p>
<p>By the way, there’s no “the” in Smokey’s name. The word was added by songwriters to make their <a href="https://www.youtube.com/watch?time_continue=11&v=cqabDpF_rd0">1952 medley</a> dedicated to the iconic image more catchy.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/OY_ZavXVC84?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Cowboy actor William Boyd, aka Hopalong Cassidy, recounted the bear’s tale in 1953.</span></figcaption>
</figure>
<h2>Wartime propaganda</h2>
<p>I researched Smokey and six other public service ad campaigns for <a href="https://www.smithsonianbooks.com/store/history/how-mcgruff-and-crying-indian-changed-america-hist/">my book about the Ad Council</a>, the nonprofit that creates public-service campaigns on behalf of clients like the U.S. Forest Service. It taught me that there’s much more going on with that friendly face than you probably realize. </p>
<p>The fire-prevention campaign, like the <a href="https://www.adcouncil.org">Ad Council</a> itself, has a past rooted in wartime propaganda. </p>
<p>A <a href="https://www.atlasobscura.com/places/monument-to-the-bombardment-of-ellwood">Japanese submarine</a> had surfaced off the coast of California on Feb. 23, 1942, and fired a volley of shells toward an oil field. This first wartime attack on the U.S. mainland caused little property damage and no loss of life, but it had an enormous psychological impact. </p>
<p>The threat to America’s national security including its vast lumber supply, needed to build ships and guns to fight the war, worried government officials and business leaders alike. The Forest Service worked with what was then known as the <a href="https://www.thedrum.com/news/2016/03/30/marketing-moment-three-ad-council-sets-shop-america-enters-world-war-ii">War Advertising Council</a>, and later became the Ad Council, to create a fire prevention campaign. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/284533/original/file-20190717-147295-l8lvn0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/284533/original/file-20190717-147295-l8lvn0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/284533/original/file-20190717-147295-l8lvn0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=790&fit=crop&dpr=1 600w, https://images.theconversation.com/files/284533/original/file-20190717-147295-l8lvn0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=790&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/284533/original/file-20190717-147295-l8lvn0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=790&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/284533/original/file-20190717-147295-l8lvn0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=993&fit=crop&dpr=1 754w, https://images.theconversation.com/files/284533/original/file-20190717-147295-l8lvn0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=993&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/284533/original/file-20190717-147295-l8lvn0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=993&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">WWII posters, like this one with a caricature of a Japanese soldier, cast taking care not to start forest fires as a patriotic duty.</span>
<span class="attribution"><a class="source" href="https://www.loc.gov/pictures/collection/wpapos/item/98518714/">Library of Congress</a></span>
</figcaption>
</figure>
<p>Some of the early posters <a href="https://msu.edu/%7Enavarro6/srop.html">harnessed the power of prejudice</a>. One depicted a caricature of a Japanese soldier with a menacing grin as he held a lighted match against the backdrop of a forest, flanked by the slogan “<a href="https://www.marshallfoundation.org/library/posters/careless-matches-aid-the-axis-prevent-forest-456/">Careless Matches Aid the Axis – Prevent Forest Fires!</a>.” Another featured sinister renditions of Adolf Hitler and Japanese Prime Minister Hideki Tojo in front of a raging forest fire with the slogan, “<a href="https://digital.library.unt.edu/ark:/67531/metadc494/">Our Carelessness, Their Secret Weapon</a>.”</p>
<p>With the war winding down in 1944, the Forest Service wanted the campaign to keep educating Americans about forest fire prevention, minus the scary imagery. After briefly featuring Bambi, the deer from the popular Walt Disney 1942 film, the Forest Service landed on a black bear. It hired New York artist Albert Staehle, who drew “Butch,” a floppy-eared cocker spaniel seen on <a href="https://wulibraries.typepad.com/mghlnews/2014/08/albert-staehle-butch.html">Saturday Evening Post covers</a>.</p>
<p>In 1944, Staehle created a <a href="https://www.nal.usda.gov/exhibits/speccoll/exhibits/show/smokey-bear/item/453">tender-looking bear</a> pouring a bucket of water over a campfire for the Forest Service. Three years later, came the well-known slogan that told Americans “<a href="https://www.adcouncil.org/Our-Campaigns/The-Classics/Wildfire-Prevention">only you can prevent forest fires</a>.”</p>
<h2>Whose land is it?</h2>
<p>Sometimes, Smokey gets caught in the middle of the campaign’s roots in World War II patriotism, propaganda and racism.</p>
<p>Some <a href="http://hdl.handle.net/1794/22259">scholars</a>, including geographer <a href="https://www.dukeupress.edu/understories">Jake Kosek</a>, who study anthropology and race even argue that the campaign is a symbol of white racist colonialism.</p>
<p>Kosek documented how the bear can trouble Native Americans, Chicanos and other people living off the land who are unhappy with the U.S. government’s land management policies. </p>
<p>In the forests of Northern New Mexico, local people see Smokey’s fire prevention message as a threat because they burn off small parts of the forest to plant crops or graze animals. Kosek found Smokey’s posters riddled with bullets in protest.</p>
<p>Kosek said the fire-suppression campaign reflects a belief, deeply rooted in the Forest Service’s history, that people who set fires in forests are deviants and evildoers. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/sCWcK0UHO7M?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">The Ad Council produced this Smokey Bear PSA in 2017.</span></figcaption>
</figure>
<h2>A Smokey effect</h2>
<p>There is also growing controversy about whether the campaign’s message <a href="https://www.jstor.org/stable/j.ctvcwnkj3">contributes to the wildfire problem</a> since research shows that some fires help forests.</p>
<p>To be sure, fire suppression as a policy didn’t originate with Smokey. It started after a <a href="https://theconversation.com/recreating-forests-of-the-past-isnt-enough-to-fix-our-wildfire-problems-59364">disastrous fire in 1910</a>.</p>
<p>In the 1930s there were <a href="https://www.stateforesters.org/newsroom/smokey-bear-guidelines/">167,277 fires</a> per year, according to a report from the Forest Service, other government agencies and the Ad Council. They credit Smokey for helping make that number fall to 106,306 in the 1990s. There may now be fewer fires, about <a href="https://www.hsdl.org/?abstract&did=813795">72,400 fires annually since 2000</a>, but they have grown <a href="https://blogs.ei.columbia.edu/2018/11/12/climate-change-california-wildfires/">larger and more destructive</a> in many regards.</p>
<p>Contrary to Smokey’s message, <a href="https://www.doi.org/10.1126/science.aab2356">fires can be good for forests</a>. There are forest management professionals who say the campaign interferes with the government’s ability to manage the problem by preventing small fires that clear out underbrush and tiny trees.</p>
<p>This is called “<a href="https://www.npr.org/2012/08/23/159373691/how-the-smokey-bear-effect-led-to-raging-wildfires">the Smokey Bear effect</a>.”</p>
<p>The Forest Service itself said this phenomenon has made forests less healthy and increased the intensity of wildfires in some areas in its 2007 report, “<a href="https://www.fs.usda.gov/treesearch/pubs/27708">Be Careful What You Wish For: The Legacy of Smokey Bear</a>.”</p>
<p>Despite his critics, Smokey seems destined for an even longer career. That’s because the <a href="https://www.iii.org/fact-statistic/facts-statistics-wildfires">Insurance Information Institute</a> says 90% of “wildland fires” in America are caused by people.</p>
<p>That could make Smokey’s message as important as ever.</p><img src="https://counter.theconversation.com/content/120207/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Wendy Melillo 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>The iconic advertising campaign originated as a way to protect the nation from its WWII enemies. Today, critics are asking if it’s causing harm as well as good.Wendy Melillo, Associate Professor, American University School of CommunicationLicensed 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/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>
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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>
<figcaption>
<span class="caption">Using a PSA test for prostate cancer remains controversial.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<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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<strong>
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>
<hr>
<p>
<em>
<strong>
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>
<hr>
<p>
<em>
<strong>
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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<strong>
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/822602017-08-09T06:03:39Z2017-08-09T06:03:39ZProstate cancer testing: has the bubble burst?<figure><img src="https://images.theconversation.com/files/181504/original/file-20170809-26039-gsnr3x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Two new studies are bursting the bubble about the value of screening men for prostate cancer.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/529736386?size=medium_jpg">from www.shutterstock.com</a></span></figcaption></figure><p>In 2010, I wrote a free book on prostate cancer testing with two colleagues, Alex Barratt (an epidemiologist) and Martin Stockler (a clinical oncologist), <a href="https://ses.library.usyd.edu.au/bitstream/2123/6835/3/Let-sleeping-dogs-lie.pdf">Let sleeping dogs lie? What men should know before getting tested for prostate cancer</a>. It has been downloaded just short of <a href="https://ses.library.usyd.edu.au/displaystats?handle=2123%2F6835&submit_simple=View+Statistics">38,000 times</a>, the highest of any item in Sydney University’s open access repository.</p>
<p>Clearly, there is understandably immense concern about prostate cancer. In 2014, 3,102 Australian <a href="http://www.aihw.gov.au/deaths/grim-books/">men died</a> from the disease, making it the second leading cause of cancer death in males after lung cancer (4,947 deaths).</p>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2099410/pdf/0513.pdf">Media reporting</a> about prostate cancer testing has long emphasised screening as highly sensible. This is consistent with other early-detection cancer-control messages about “finding it early”. </p>
<p>However, news reports often neglect to mention or minimise adverse consequences of interventions following the surgery and radiation that can follow a positive screening test, like long-term sexual impotence and incontinence.</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>There’s also a pitch to gender equity (“women have their cancer tests, and men have this one”). Those questioning testing have been vilified, and epidemiological details framed as an inferior form of knowledge than clinical experience.</p>
<p>Ten years ago, <a href="https://www.mja.com.au/journal/2007/187/9/news-not-all-good-misrepresentations-and-inaccuracies-australian-news-media">a study</a> of Australian media reports found 10% of a large sample of statements in news reports were inaccurate or misleading and concluded:</p>
<blockquote>
<p>Despite near universal lack of support for prostate cancer screening of asymptomatic men by leading international and Australian cancer control agencies, Australians are exposed to an unbalanced stream of encouragement to seek testing. This coverage includes inaccurate information which ignores scientific evidence and the general lack of expert agency support.</p>
</blockquote>
<p>Since we published our book, many men have contacted me thanking us for writing it. But I’ve also been taken aside by others with this message: “Look, I know about all the controversy about prostate cancer testing but my husband had the test and his doctor said he was so lucky that they found it early because it was very advanced and if they’d left it any longer, he’d have almost certainly died from it.”</p>
<p>I reply that I of course have no idea what the test and subsequent biopsy showed and so I could not possibly comment. In some cases, this will be true, but as we shall see, in many more cases it won’t be.</p>
<h2>Why are men unlikely to question advice?</h2>
<p>People who have been told by a specialist urologist that they are at serious risk of death are naturally unlikely to question what they are told. Having climbed on board the testing, biopsy and radical treatment “train” and being still alive to tell their story, they have what is often called “survivor joie de vivre”.</p>
<p>They are utterly convinced that the cancer discovery and radical intervention (surgical prostate removal or radiation therapy) has saved their lives. They can be evangelical about their luck, even when <a href="http://www.bmj.com/content/339/bmj.b4817">77% live with sexual impotence</a> three years after surgery. As some will tell you, “you can’t have sex in a coffin”.</p>
<p>But such accounts do not tell us whether testing and subsequent intervention really save lives. Here, the evidence needs to come from longitudinal studies of men who are found to have elevated prostate specific antigen (PSA) test results (including men who have not been tested) and who are then randomised into different treatments (including no treatment).</p>
<p>Seven years after we summarised available knowledge on this in our 2010 book, we now have results from two recent clinical trials to help us make even stronger informed decisions: the Prostate Testing for Cancer and Treatment (<a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1606220#t=article">ProtecT</a>) – 10 years of follow-up - and Prostate Cancer Intervention versus Observation Trial (<a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1615869">PIVOT</a>) – 20 years of follow-up.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/latest-research-shows-surgery-for-early-stage-prostate-cancer-doesnt-save-lives-81089">Latest research shows surgery for early stage prostate cancer doesn't save lives</a>
</strong>
</em>
</p>
<hr>
<p>Two Australian oncologists, Ian Haines and George Miklos, have given us an important, <a href="https://www.doctorportal.com.au/mjainsight/2017/29/latest-data-on-prostate-cancer-treatment-jaw-dropping-and-clear-cut/?platform=hootsuite">excoriating summary</a> of these two studies. They conclude the data:</p>
<blockquote>
<p>… completely undermine the stratospheric spin associated with prostate cancer being a death sentence. They are unambiguous in their implications … The bottom line? Men with early stage abnormalities of the prostate who do not undergo surgery or radiation treatment, but whose condition is monitored for any progression of the cancer, live just as long as men who opted for complete removal of the prostate and who now live with its immediate consequences, including incontinence, intimacy issues, bowel problems and intervention regret.</p>
</blockquote>
<h2>What do the data say?</h2>
<p>The Australian Institute of Health and Welfare (AIHW) collates all incidence and mortality data for <a href="http://www.aihw.gov.au/deaths/grim-books/">all cancers</a>. This figure shows the median age of death in men from various cancers and all causes of death combined for 2014, the latest available year.</p>
<iframe id="datawrapper-chart-SPesn" src="https://datawrapper.dwcdn.net/SPesn/2/" scrolling="no" frameborder="0" allowtransparency="true" allowfullscreen="allowfullscreen" webkitallowfullscreen="webkitallowfullscreen" mozallowfullscreen="mozallowfullscreen" oallowfullscreen="oallowfullscreen" msallowfullscreen="msallowfullscreen" width="100%" height="255"></iframe>
<p>This shows that prostate cancer is very clearly a disease that mostly kills very late in life. The average age of death for prostate cancer in Australia is 82 years, while the median age for all male cancers combined (other than prostate cancer) is 75 – considerably younger. </p>
<p>Sixty percent of men who die from the disease are aged 80 or over with 87% aged 70 or more. Just 2.1% (65 men) who died from the disease were aged under 60, and three (0.1%) were aged under 50.</p>
<p>Significantly, the average age of death (from all causes combined) for an Australian man in 2014 was 78 years.</p>
<p>So men who die from any cause after that time – prostate cancer included – are already living longer than average. Prostate cancer is one disease in the Grim Reaper’s quiver at the end of our lives. As we all must will die from some cause, it’s worth reflecting on why so much attention should be given to a disease that stands out so obviously as one that kills most very late in life.<br>
In 2014, prostate cancer <a href="http://www.aihw.gov.au/deaths/grim-books/">killed</a> 3,102 males out of 78,341 deaths from all causes (4%). It’s long been remarked that far more men die with prostate cancer than from it. We know from <a href="https://www.ncbi.nlm.nih.gov/pubmed/18304396">autopsy studies</a> that around 40% of men in their 40s will have signs of prostate cancer, with this increasing to about 60% of men in their 60s. Clearly then, the great majority of men who develop prostate cancer will not die from it but from something else.</p>
<p>Yet the drive to promote prostate testing continues unabated, which is causing massive anxiety, intervention and significant decrements to the quality of life of men who are treated unnecessarily. Haines and Miklos point the finger at financial reasons for this over-treatment.</p>
<blockquote>
<p>It will be even more difficult to dislodge early PSA testing, particularly in countries such as the United States, where it has now become deeply entrenched in a belief-based or business enterprise. After all, given the huge investments in proton-based radiation facilities (where it costs in excess of $300 million to just build a proton beam facility), or in robotic surgery machines, the financial incentives to repay the investment and to move to a for-profit situation are huge. A constant supply of patients is obligatory, and an increasing supply is preferable.</p>
</blockquote>
<p>Many male doctors <a href="https://theconversation.com/why-do-doctors-keep-silent-about-their-own-prostate-cancer-testing-decisions-36424">do not have PSA tests</a> themselves. As more information emerges that challenges the wisdom of the promotion of prostate testing, we need to ask whether this bubble is near to bursting.</p><img src="https://counter.theconversation.com/content/82260/count.gif" alt="The Conversation" width="1" height="1" />
Two major studies cast doubt on the value of screening for prostate cancer, yet it continues regardless.Simon Chapman, Emeritus Professor in Public Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/482392015-09-29T02:27:34Z2015-09-29T02:27:34ZCostly and harmful: we need to tame the tsunami of too much medicine<figure><img src="https://images.theconversation.com/files/96562/original/image-20150929-30976-vga2ax.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">GPs have increased their test ordering by more than 50%. Imaging for back pain is one of the key culprits.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/white_ribbons/6090449846/">lauren rushing/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span></figcaption></figure><p>ABC’s Four Corners program on <a href="http://www.abc.net.au/4corners/stories/2015/09/28/4318883.htm">waste in health care</a> didn’t pull any punches. “Many common treatments are often unnecessary, ineffective, or worse still harmful,” said presenter Kerry O’Brien, introducing a special investigation narrated by long-time ABC health reporter Dr Norman Swan. “Waste runs into tens of billions of dollars a year – much of it due to overdiagnosis and the ill-advised treatments that follow.” </p>
<p>For those who missed it, last night’s program focused on several high-cost areas of health care where the evidence suggests that too much medicine is doing us more harm than good: knee pain, back pain, chest pain and PSA (prostate specific antigen) screening for prostate cancer. </p>
<p>The program’s key targets were sophisticated and expensive medical tests – such as <a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/ct_scan">computed tomography</a> (CT) scans and magnetic resonance imaging (MRIs) – being ordered in ever greater numbers, often unnecessarily. In the past ten years for example, GPs have increased their test ordering by more than 50%. This equates to around four million extra tests a year. </p>
<p>While it might seem like common sense to want to take a test to see what’s wrong, the problem is that test results can often be misleading and unhelpful – and can start a cascade of further unnecessary tests and treatments. </p>
<h2>‘Fixing’ ageing knees</h2>
<p>Take knee pain, for example. In the Four Corners program, Professor Rachelle Buchbinder explained that if you give MRIs to healthy people who have no knee pain, you will still find “abnormalities” in their MRI results. This is partly because of the normal wear and tear associated with ageing.</p>
<p>“A picture in medicine does not always tell a story – a positive test may not mean a thing,” said Swan. “We’re getting a whole lot of knee scans that we don’t need and which cause us risk and expense.” </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/96567/original/image-20150929-30970-1b3jq1t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/96567/original/image-20150929-30970-1b3jq1t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/96567/original/image-20150929-30970-1b3jq1t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/96567/original/image-20150929-30970-1b3jq1t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/96567/original/image-20150929-30970-1b3jq1t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/96567/original/image-20150929-30970-1b3jq1t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/96567/original/image-20150929-30970-1b3jq1t.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">Arthroscopies are needlessly performed for osteoarthritis of the knee.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/21072575@N00/3567686583/">Laundry Broad/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>The knee example gets worse. </p>
<p>The unnecessary MRI might show some “abnormality” with the knee which has nothing to do with your pain, but is worrying enough to land you with an orthopedic surgeon who recommends and performs an arthroscopy. </p>
<p>But as Buchbinder pointed out, there is evidence, from the <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa013259">New England Journal of Medicine</a> no less, suggesting arthroscopy for osteoarthritis of the knee is no better than sham surgery or placebo. More recent evidence, again from the <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1305189">NEJM</a>, suggests arthroscopy to clean up a tear to the meniscus is also no better than sham surgery. </p>
<h2>Too much agreement</h2>
<p>One criticism of the Four Corners program is that almost all the interviewees shared the view Australia is doing too many tests and treatments, and urgently needs to wind them back. We didn’t hear anyone take the view we need <em>more</em> medicine not less. </p>
<p>To counter that criticism, and in defence of the program, one of the important roles of investigative media is sometimes to take a perspective and run an argument. There’s undeniably mounting evidence of <a href="https://theconversation.com/au/topics/overdiagnosis">overuse and overdiagnosis</a>, and the scientific credibility of those interviewed was impeccable. </p>
<p>Take Dr Robyn Ward, a cancer specialist and chair of Australia’s Medical Services Advisory Committee, which uses an evidence-based approach to assess new tests and procedures. “Often the best medicine is no medicine at all, or the best intervention is no intervention at all,” said Ward, who sees Australia’s fee-for-service system, which largely rewards doctors for throughput, as one of the drivers of excess. </p>
<p>Other drivers covered in the program included professional interests, commercial forces, technological change, expanding disease definitions, patient demand and cultural faith in early detection.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/96568/original/image-20150929-30984-tdwmmw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/96568/original/image-20150929-30984-tdwmmw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/96568/original/image-20150929-30984-tdwmmw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/96568/original/image-20150929-30984-tdwmmw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/96568/original/image-20150929-30984-tdwmmw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/96568/original/image-20150929-30984-tdwmmw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/96568/original/image-20150929-30984-tdwmmw.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">Professional interests and expanding disease definition can drive overdiagnosis.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/proimos/6870109454/">Alex Proimos/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span>
</figcaption>
</figure>
<p>Another interviewee was Associate Professor Adam Elshaug, who has produced internationally respected work on what’s called “low-value care”. His landmark article, published in the <a href="https://www.mja.com.au/journal/2012/197/10/over-150-potentially-low-value-health-care-practices-australian-study">Medical Journal of Australia</a> in 2012, listed scores of tests and treatments that are being overused or misused. </p>
<h2>A third of health-care costs squandered</h2>
<p>One of the key claims in the Four Corners program was that almost a third of the money being spent on health care is “squandered”. If you include everything we spend, that’s potentially A$46 billion a year wasted. </p>
<p>While this may well be the case in Australia, it’s perhaps worth pointing out that this estimate arises from studies in the United States. </p>
<p>A key paper in the <a href="http://jama.jamanetwork.com/article.aspx?articleid=1148376">Journal of the American Medical Association</a> in 2012 estimated that total health-care waste in the US – including overtreatment, fraud, administrative complexity and other flaws – accounted for between 20% and 50% of the total cost of health care – with the midpoint estimate being 34%. Hence the one-third figure. </p>
<p>To my knowledge, there are as yet no similarly rigorous estimates of waste in Australian health care. </p>
<h2>Where to from here?</h2>
<p>The federal government is running a major review of all tests and treatments covered by Medicare, with <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/consultation-mbsreviewtaskforce">consultation papers</a> released on the weekend. </p>
<p>According to those documents, a key objective of the review “is to eliminate the funding of low-value or inappropriate health services — that is, treatments, procedures and tests which are of little or no clinical benefit, through overuse or misuse, and which in some cases might actually cause harm to patients”. </p>
<p>Apart from the harms, there is also the tsunami of rapidly rising costs of health care, due in part to ageing, in part to more expensive pills and technology, and in part to overdiagnosis and overtreatment. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/96557/original/image-20150929-30976-1c2bv3t.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/96557/original/image-20150929-30976-1c2bv3t.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/96557/original/image-20150929-30976-1c2bv3t.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=404&fit=crop&dpr=1 600w, https://images.theconversation.com/files/96557/original/image-20150929-30976-1c2bv3t.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=404&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/96557/original/image-20150929-30976-1c2bv3t.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=404&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/96557/original/image-20150929-30976-1c2bv3t.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=507&fit=crop&dpr=1 754w, https://images.theconversation.com/files/96557/original/image-20150929-30976-1c2bv3t.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=507&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/96557/original/image-20150929-30976-1c2bv3t.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=507&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Growth in Medicare benefits; 1983–84 to 2014–15.</span>
<span class="attribution"><a class="source" href="http://www.health.gov.au/internet/main/publishing.nsf/Content/922CB2933B0F1645CA257EC1001D5C12/$File/MBS%20Review_Consultation%20paper_Overview_FINAL.pdf">MBS Review Consultation Paper Overview, September 2015</a></span>
</figcaption>
</figure>
<p>The national review is expected to report in coming years – though likely only after complex horse-trading over many of the 5,700 items on the Medicare schedule, as doctors debate exactly what is appropriate and what’s not. </p>
<p>In the meantime the best approach is a healthy scepticism and as many questions to your doctor as you can squeeze in. Do I really need that test or treatment? Do I really need that diagnosis? Where’s the evidence? And, perhaps most importantly, what happens if I do nothing? </p>
<p>Believe it or not, doing nothing is often the best medical care you could get.</p>
<p>Who knows, maybe the tide of too much medicine is turning. But can a tsunami can be tamed?</p><img src="https://counter.theconversation.com/content/48239/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr Ray Moynihan has received funding from Bond University for studies on overdiagnosis. He has written widely on the problem of too much medicine, is a colleague to several of the program interviewees, and is a co-organizer of the international Preventing Overdiagnosis scientific conferences and the national Preventing Overdiagnosis and Overuse meeting. </span></em></p>The evidence suggests too much medicine is doing us harm, particularly when treating knee pain, back pain, chest pain and screening for prostate cancer.Ray Moynihan, Senior Research Fellow, Bond UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/439002015-07-06T09:48:48Z2015-07-06T09:48:48ZCan public service announcements take a bite out of Shark Week?<figure><img src="https://images.theconversation.com/files/87190/original/image-20150702-11323-hkcrju.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Sensationalized shark attacks skew the facts.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?searchterm=sharks&keyword_search=1&page=2&thumb_size=mosaic&inline=273522929">'Shark' via www.shutterstock.com</a></span></figcaption></figure><p>This week, millions of Americans will tune into Shark Week, the Discovery Channel’s popular annual tribute – now in its 28th year – to the ocean’s most infamous predators.</p>
<p>But how does watching Shark Week actually affect people’s beliefs and feelings about sharks?</p>
<p>That’s what we set out to discover in our <a href="http://scx.sagepub.com/content/36/5/544.abstract">recent study</a>, which looked at the effects of watching video of sharks alongside public service announcements (PSAs) about the need for shark conservation. </p>
<h2>Which species should be afraid?</h2>
<p>Shark Week is famous for portraying sharks as deadly predators that threaten our status as the world’s top species. But in fact, sharks should fear us a lot more. </p>
<p><a href="http://news.discovery.com/earth/oceans/100-million-sharks-killed-annually-130305.htm">Up to 100 million sharks are killed every year</a>, whether it’s for the popular Chinese dish shark fin soup or as accidental bycatch. Meanwhile, <a href="http://www.flmnh.ufl.edu/fish/sharks/isaf/2014Summary.html">fewer than five people are killed by sharks every year</a>. Based on these statistics, you’re far more likely to die from a bee sting or the flu than you are to be killed by a shark.</p>
<p>This fact puts scientists and marine conservationists in a bind when it comes to Shark Week. </p>
<p>On the one hand, the series draws a vast audience of people who are interested in sharks. On the other hand, Shark Week then plies that audience with violent imagery of sharks that paints them as, well, less than sympathetic (to put it mildly), and not exactly worthy of protection. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/87189/original/image-20150702-11301-1t6yv0k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/87189/original/image-20150702-11301-1t6yv0k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=419&fit=crop&dpr=1 600w, https://images.theconversation.com/files/87189/original/image-20150702-11301-1t6yv0k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=419&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/87189/original/image-20150702-11301-1t6yv0k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=419&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/87189/original/image-20150702-11301-1t6yv0k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=526&fit=crop&dpr=1 754w, https://images.theconversation.com/files/87189/original/image-20150702-11301-1t6yv0k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=526&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/87189/original/image-20150702-11301-1t6yv0k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=526&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Discovery Channel headquarters in Silver Spring, Maryland got a makeover for Shark Week in 2006.</span>
<span class="attribution"><a class="source" href="https://upload.wikimedia.org/wikipedia/commons/f/f7/Discovery_Building_Shark_Week_2.jpg">Farragutful/Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>Healthy shark populations are important for the oceans because they keep the systems of interdependent food chains in balance, which protects both the seafood species that we like to eat and the marine mammals that we find a bit more cuddly. </p>
<p>We wanted to find out if PSAs from marine conservation organizations stating the facts about sharks would mitigate people’s emotional reactions to the violent imagery often shown on Shark Week.</p>
<p>So we paired clips from Shark Week that contained varying levels of violence with conservation-focused PSAs. We used highly violent Shark Week clips showing a shark tearing into a person, causing serious injury; moderately violent ones in which a shark bites a person who sustained no injuries; and nonviolent clips that showed sharks simply swimming.</p>
<p>We used actual shark conservation PSAs in our study, which participants watched after they saw a clip from Shark Week – <a href="https://www.youtube.com/watch?v=ySowHT8QvQ0">one from Pew</a> and <a href="https://vimeo.com/4891090">one from Oceana</a>. (Oceana’s “Scared for Sharks” PSA featuring actress January Jones actually did run during Shark Week in past years.) Both PSAs informed viewers that their actual risk of being attacked was quite low but that sharks are killed in high numbers by humans.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/ySowHT8QvQ0?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">A 2012 PSA on sharks from Pew.</span></figcaption>
</figure>
<h2>‘Mean ocean syndrome’ for some; new ocean advocacy for others</h2>
<p>More than 500 people watched the clips and reported their reactions, and it turns out that violent Shark Week content, whether paired with a PSA or not, caused a fearful reaction in people. </p>
<p>No matter what, sharks are scary – especially in high definition. </p>
<p>Watching a PSA didn’t mitigate people’s fearful reactions, and people continued to overestimate their own risk of being attacked by a shark, even when presented with the facts. </p>
<p>We call this “mean ocean syndrome,” a variant of <a href="http://www.theatlantic.com/magazine/archive/1997/05/the-man-who-counts-the-killings/376850/">mean world syndrome</a>: the idea that people who watch a lot of violent crime drama on television tend to overstate their likelihood of being a victim of a crime. </p>
<p>Likewise, television programming that depicts the ocean as a violent place will cause people to overestimate the danger to themselves when they go in the water.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/87174/original/image-20150702-11318-qpu12p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/87174/original/image-20150702-11318-qpu12p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=373&fit=crop&dpr=1 600w, https://images.theconversation.com/files/87174/original/image-20150702-11318-qpu12p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=373&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/87174/original/image-20150702-11318-qpu12p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=373&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/87174/original/image-20150702-11318-qpu12p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=469&fit=crop&dpr=1 754w, https://images.theconversation.com/files/87174/original/image-20150702-11318-qpu12p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=469&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/87174/original/image-20150702-11318-qpu12p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=469&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">People continue to overestimate the danger sharks pose.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/s/sharks/search.html?page=2&thumb_size=mosaic&inline=128042789">'Kayak' via www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>But here’s what the PSAs did do. </p>
<p>For many viewers, especially younger women, the PSAs prompted an increased interest in shark conservation and an intent to do things like donate to a conservation organization or support legislation that protects sharks. </p>
<p>That’s major. It means that Shark Week has the opportunity to turn at least some of its viewers into ocean advocates. Given that some shark species are <a href="http://elifesciences.org/content/3/e00590.abstract">already headed toward extinction</a>, Shark Week could end up being an unlikely savior for sharks – that is, if the Discovery Channel wants to use its vast reach to protect the creatures that have earned the network millions of dollars.</p><img src="https://counter.theconversation.com/content/43900/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 organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Millions tune in to Shark Week each year, but many walk away with the wrong impressions.Suzannah Evans, PhD candidate in Journalism & Mass Communication, University of North Carolina at Chapel HillJessica Myrick, Assistant Professor of Media, Indiana UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/364242015-01-19T01:35:17Z2015-01-19T01:35:17ZWhy do doctors keep silent about their own prostate cancer testing decisions?<p>Across 38 years in tobacco control, I have been asked countless times in media interviews if I ever smoked. It’s often an early question. I always unhesitatingly explain that I did: I stopped in my mid 20s. The tone of the interview immediately relaxes because the sub-text of the question is about authenticity. If this person has never smoked, what would he really know about quitting? If I chose to stammer something about it being private or “not the point here”, most would become preoccupied with my evasiveness. Fudging and equivocal replies tend to suggest disingenuousness or lack of personal conviction about the information being given. </p>
<p>Clinicians tell me they’re frequently asked by patients “what would you do, doctor?” The question might mean either “what would you do if you were <em>me</em>?” But it might also be an invitation to a doctor to explain their own personal health decisions. The question can refer to anything from diet, dietary supplement use, organ donation, beating jet lag, travel medicine or exercise. It’s normal to ask friends and family what they do in health matters, so when you come face to face with someone who’s supposed to know a lot about health, wanting to know if they personally practice some behaviour is an obvious question.</p>
<p>Many health-related practices are openly observable. So if you know or associate with health workers, you can see if they are wear a hat in the sun, walk or cycle to work, take the elevator when stairs are available, or hit the drink at social events. But many health practices are not obvious and require disclosure if we are to know what someone does.</p>
<p>Few would ask their doctor about his or her alcohol intake, and even fewer would ask about their sexual behaviour (condom use or contraception) because these questions cross obvious privacy boundaries. A corpulent doctor is unlikely to be asked about their diet or the extent of their exercise regimen but a lean doctor might well be because of differences in the social meaning of body size. But it’s not obvious that screening tests, check-ups, and dietary practices and supplementation cross privacy boundaries, particularly when patients are likely to have read conflicting information and material inviting them to discuss testing with their doctors. </p>
<p>But when it comes to prostate cancer screening, men in the medical profession – with <a href="https://theconversation.com/four-reasons-i-wont-have-a-prostate-cancer-blood-test-35085">rare exceptions</a> – keep their heads well down from public disclosure. In 2003, the then head of the Cancer Council Australia Professor Alan Coates (then aged 59) told Jill Margo, health reporter at the Australian Financial Review, that he had not personally been tested for prostate cancer and did not plan to be. Despite there being no government position on prostate specific antigen (PSA) testing and considerable professional criticism of the practice, Coates was subjected to astonishing vilification, including a vicious spray on <a href="http://www.abc.net.au/7.30/content/2003/s796549.htm">national television</a> from senior Labor politician Wayne Swan, who had personal experience of the disease.</p>
<p>I know that many people privately thanked Coates for his frankness which did much to open up much needed public discussion of prostate screening in Australia.</p>
<p>With two other colleagues, I wrote a book in 2010 <a href="http://ses.library.usyd.edu.au/bitstream/2123/6835/3/Let-sleeping-dogs-lie.pdf">Let sleeping dogs lie: What men should know before getting tested for prostate cancer</a>. The free-download book has had a remarkable 26,500 downloads. Knowing it was likely that I would be asked if I had been tested, I decided to be open about it and explain why I had not when the book was published.</p>
<p>Discussion about the book with colleagues in my own faculty quickly revealed that many men past their fifties had also chosen not to have a PSA test. Several had not consented to be tested, but were given their PSA result after their GP had taken the decision for them and added PSA testing to a blood sample drawn for other reasons. I suggested to some that they might do men’s health a service by explaining publicly why they have chosen to not be tested.</p>
<p>About five years ago, the Clinical Oncology Society of Australia allowed me to survey its members about their personal cancer prevention and screening practices. Confidentiality was assured, but the response rate was so low that the data were unusable. The most recent information I know about Australian doctors own prostate screening practices is now 18 years out of date (1997). Then, 55% of a sample of <a href="http://www.ncbi.nlm.nih.gov/pubmed/?term=Livingstone+Borland+prostate">Victorian male GPs</a> aged over 49 had chosen to not have a PSA test themselves.</p>
<p>With widespread publicity being given to problems of unnecessary over-diagnosis and the very serious problems that can follow from this (anxiety or depression in living with a cancer diagnosis, permanent impotence and incontinence), it is possible and even likely that an even higher proportion of Australian doctors today will have elected to not be tested. But we don’t know.</p>
<p>The recent draft <a href="http://wiki.cancer.org.au/australiawiki/img_auth.php/d/d5/20141125_Draft_Clinical_Practice_Guidelines_PSA_Testing.pdf">report</a> from the Prostate Cancer Foundation and Cancer Council Australia recommends men and their doctors fully explore the risks and benefits of prostate testing. In that spirit, if the subject comes up when you are next seeing your (male) doctor, ask him whether and why he has chosen to be tested or not. What you hear (or don’t hear) might be very revealing.</p>
<p><em><strong>Editor’s note: please ensure your comments are <a href="https://theconversation.com/au/community-standards">courteous and on-topic</a>.</strong></em></p><img src="https://counter.theconversation.com/content/36424/count.gif" alt="The Conversation" width="1" height="1" />
Across 38 years in tobacco control, I have been asked countless times in media interviews if I ever smoked. It’s often an early question. I always unhesitatingly explain that I did: I stopped in my mid…Simon Chapman, Professor of Public Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/187872013-10-31T19:35:45Z2013-10-31T19:35:45ZMovember messaging: getting to the bottom of prostate cancer testing<figure><img src="https://images.theconversation.com/files/33763/original/2zs75yrr-1382669814.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Professional organisations offer conflicting recommendations on the merits of PSA testing for prostate cancer.</span> <span class="attribution"><span class="source">Flickr/anaxolotl</span></span></figcaption></figure><p>The Movember campaign, which encourages men to grow moustaches each November to raise funds and awareness for men’s health, has helped raise the profile of prostate cancer. Statistics such as “one in eight Australian men will develop prostate cancer in their lifetime” provide men with an impetus to see their general practitioner (GP) and <a href="http://au.movember.com/mens-health/prostate-cancer">get tested</a> for prostate cancer. </p>
<p>That’s good, right? Well, not quite. Not all men should be tested for prostate cancer. In fact, for some men, it can do more harm than good. </p>
<h2>Testing for cancer</h2>
<p>Testing for prostate cancer involves the use of two tests which can be done individually or in combination: the digital rectal examination (DRE) and the prostate specific antigen (PSA) test. </p>
<p>The DRE was commonly used as a front-line test for prostate cancer before the PSA test became available in the early 1990s. Use of the DRE in testing for prostate cancer <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3302122/">is limited</a>, since it is impossible to examine the entire prostate gland due to the anatomical location of the prostate gland itself. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/33767/original/5zkpgpv8-1382671539.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/33767/original/5zkpgpv8-1382671539.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/33767/original/5zkpgpv8-1382671539.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=433&fit=crop&dpr=1 600w, https://images.theconversation.com/files/33767/original/5zkpgpv8-1382671539.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=433&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/33767/original/5zkpgpv8-1382671539.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=433&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/33767/original/5zkpgpv8-1382671539.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=544&fit=crop&dpr=1 754w, https://images.theconversation.com/files/33767/original/5zkpgpv8-1382671539.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=544&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/33767/original/5zkpgpv8-1382671539.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=544&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>
<span class="attribution"><span class="source">enochchoi</span></span>
</figcaption>
</figure>
<p>Given the limitations of the DRE, the PSA test is commonly used as the front-line test for prostate cancer. PSA is a <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3302122/">protein</a> that is made in the prostate gland and can be measured via a blood test to assist in diagnosing prostate disease. </p>
<p>The PSA test is not cancer specific, as a raised PSA level may also be indicative of a benign growth of the prostate gland or an inflammation of the prostate gland.</p>
<h2>How effective is the PSA?</h2>
<p>A <a href="http://www.ncbi.nlm.nih.gov/pubmed/19744336">2009 systematic review</a> examining the accuracy of the PSA test in diagnosing prostate cancer determined the sensitivity of the PSA test ranged from 78% to 100%. This means the PSA test may fail to diagnose more than one in five cases where prostate cancer is present.</p>
<p>The review also found the specificity of PSA tests ranged from 6% to 66%, which means the PSA test may incorrectly “diagnose” prostate cancer in the majority of patients who test positive to the PSA test, when in fact, they do not have the disease. </p>
<p>This “over-diagnosis” is a common harm of PSA-testing, whereby patients who do not have any symptoms are diagnosed with a disease that would never otherwise cause them symptoms or lead to their early death. </p>
<p>Over-diagnosis may involve further investigation through an invasive biopsy of the prostate gland, followed by unnecessary treatment. This can lead to significant emotional and physical side effects including erectile dysfunction and incontinence. </p>
<p>The <a href="http://www.ncbi.nlm.nih.gov/pubmed/23440794">2013 Cochrane systematic review</a> on screening for prostate cancer, which pooled analyses of five randomised controlled trials, concluded that screening did not significantly decrease prostate cancer-related deaths but that harms such as over-diagnosis were common. </p>
<h2>Conflicting advice</h2>
<p>Professional organisations offer conflicting recommendations on the merits of and recommendations for PSA testing for prostate cancer, leaving middle-aged men understandably confused. </p>
<p>The Prostate Cancer Foundation of Australia (PCFA) <a href="http://www.prostate.org.au/articleLive/attachments/1/PCFA_Policy_on_Testing_Asymptomatic_Men_for_Prostate_Cancer.pdf">recommends</a>: </p>
<blockquote>
<p>… men over age 50, or 40 with a family history of prostate cancer, should talk to their doctor about testing for prostate cancer using the PSA test and DRE as part of their annual health check-up. </p>
</blockquote>
<p>The Royal Australian College of General Practitioners (RACGP) <a href="http://www.racgp.org.au/your-practice/guidelines/redbook/early-detection-of-cancers/prostate-cancer/">guidelines say</a>:</p>
<blockquote>
<p>Screening for prostate cancer is not recommended unless the man specifically asks for it; and he is fully counselled on the pros and cons.</p>
</blockquote>
<p>Finally, the Urological Society of Australia and New Zealand (USANZ) <a href="http://www.usanz.org.au/uploads/29168/ufiles/USANZ_PSA_Testing_Policy.pdf">argues</a>: </p>
<blockquote>
<p>… PSA based testing and subsequent treatment where appropriate, has been shown to reduce prostate cancer mortality in large randomised studies and therefore should be offered to men after informing them of the risks and benefits of such testing. </p>
</blockquote>
<p>Much of the disagreement between medical and health bodies can be attributed to how evidence from the five randomised controlled trials is interpreted. </p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/33779/original/64fqmqvj-1382675109.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/33779/original/64fqmqvj-1382675109.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/33779/original/64fqmqvj-1382675109.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/33779/original/64fqmqvj-1382675109.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/33779/original/64fqmqvj-1382675109.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/33779/original/64fqmqvj-1382675109.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/33779/original/64fqmqvj-1382675109.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/33779/original/64fqmqvj-1382675109.jpg?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">With conflicting findings, the value of PSA testing comes down to interpretation.</span>
<span class="attribution"><span class="source">Thirteen Of Clubs</span></span>
</figcaption>
</figure>
<p>Only two of the trials, the <a href="http://www.erspc-media.org/">European Randomized Study of Screening for Prostate Cancer</a> (ERSPC) and the US <a href="http://prevention.cancer.gov/plco">Prostate, Lung, Colorectal and Ovarian</a> (PLCO) Cancer Screening Trial have been accepted as being methodological “sound”, yet provide conflicting results.</p>
<p>The ERSPC study reports a 21% reduction in the risk of prostate cancer death among a core subgroup of men aged 55 to 69 years, whereas the PLCO study reports no significant difference in prostate cancer death in men aged 55 to 74 years. </p>
<p>Differences in participants’ prior history of PSA testing, motivation to comply with the testing routine, PSA cut-off thresholds, screening intervals and treatment options, may contribute to the conflicting findings. </p>
<p>The ERSPC study, for example, used a PSA cut-off ranging from 2.5 to 4 nanograms per millilitre, while the PLCO study’s cut-off was 4 nanograms per millilitre. The PLCO study offered men annual PSA testing for six years and DRE for four years, while the majority of sites in the ERSPC study offered PSA testing to men every four years. </p>
<p>How professional bodies interpret these differences, and the weight attributed to each difference, may account for the disparity in recommendations.</p>
<h2>So, should I get tested?</h2>
<p>The RACGP provides Australian GPs with a clear recommendation not to provide PSA testing unless specifically asked. What GPs may struggle with is how best to counsel men about the benefits and limitations of PSA testing, given the usual ten to 15 minute consultation time.
<a href="http://www.prostate.org.au/articleLive/attachments/1/GP%20Show%20Card%20041007.pdf">Decision aids</a> and <a href="http://www.prostatecancer-riskcalculator.com/seven-prostate-cancer-risk-calculators">risk calculators</a>, however, can help guide the discussion. </p>
<p>If you ask for a PSA test, your GP will likely ask why you’re concerned about prostate cancer and talk to you about your individual risk factors such as a family history of the disease. Your GP will also discuss the pros and cons of early detection and treatment. </p>
<p>On considering your absolute risk of developing prostate cancer and what benefit, if any, PSA testing may have, you’ll be better placed to decide whether it’s worth it. </p><img src="https://counter.theconversation.com/content/18787/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dragan Ilic is lead author of the Cochrane systematic review on screening for prostate cancer. </span></em></p>The Movember campaign, which encourages men to grow moustaches each November to raise funds and awareness for men’s health, has helped raise the profile of prostate cancer. Statistics such as “one in eight…Dragan Ilic, Associate Professor, Department of Epidemiology and Preventive Medicine, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/90542012-09-18T20:46:47Z2012-09-18T20:46:47ZThe ethics of over-diagnosis: risk and responsibility in medicine<figure><img src="https://images.theconversation.com/files/15597/original/vqbb6t59-1347933082.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Over-diagnosis and over-treatment happen for many reasons – and consumers contribute as well.</span> <span class="attribution"><span class="source">www.shutterstock.com</span></span></figcaption></figure><p><em>OVERDIAGNOSIS EPIDEMIC – Today, Stacy Carter presents a philosophical view of over-diagnosis and what can be done to change how things stand.</em></p>
<p>Recently a friend told me a story about her dad. Fit and well, he had a PSA test during a general medical check-up. The PSA test is controversial: many, <a href="http://www.nytimes.com/2010/03/10/opinion/10Ablin.html">including its inventor</a>, say it should never be used to screen for cancer. </p>
<p>My friend’s dad’s PSA test started him on a path to prostate cancer diagnosis and surgery. The surgery made him incontinent. Humiliated by accidents, he couldn’t be far from a toilet so could no longer coach soccer or go on his daily long walk with friends. He became socially isolated and sedentary. He put on weight. And he developed diabetes. </p>
<p>Now his health is worse, but it’s not only his health that has been affected. Other aspects of his well-being – attachment to his friends and the ability to live the life he wants – have been undermined. His story is, sadly, <a href="http://purl.library.usyd.edu.au/sup/9781920899684">not unusual</a>, except for one thing. </p>
<p>The hospital where he was treated called him in to apologise for operating unnecessarily and harming him. Both he and his clinicians concede he was over-diagnosed (the disease would not have produced symptoms or shortened his life) and over-treated (he received treatment he didn’t need.)</p>
<h2>The popularity of screening</h2>
<p>Over-diagnosis and over-treatment <a href="http://books.google.com.au/books?id=qe7XQxzAftEC&lpg=PP1&ots=GNPJRp2bDX&dq=overdiagnosed">happen for many reasons</a> – commercial interests, technological developments, medico-legal threats <a href="http://books.google.com.au/books?id=fftKR4y2NMIC&dq=Selling+Sickness:+How+the+worlds+biggest+drug+companies+are+turning+us+all+into+patients">and deliberate profiteering</a>. But as consumers, we also contribute. </p>
<p>In one <a href="http://www.ncbi.nlm.nih.gov/pubmed/17644829">British study</a>, men described turning up to their GP determined to have a PSA test. In an <a href="http://www.ncbi.nlm.nih.gov/pubmed/19579539">Australian one</a>, women worried that expert disagreement on PSA testing might discourage men from being screened. <a href="http://jama.jamanetwork.com/article.aspx?articleid=197942">Most respondents</a> to a US survey were enthusiastic about cancer screening, with 73% saying they’d rather have a full-body CT scan than $1,000 cash. Many thought it was <em>irresponsible</em> for healthy adults to avoid cancer screening. </p>
<p>We’re not just willing to go fishing for diseases. Some of us think it’s a moral obligation. And this is not surprising given two commonly accepted characteristics of contemporary Western society: we expect to be able to <a href="http://onlinelibrary.wiley.com/doi/10.1111/1468-2230.00188/abstract">predict and control the future</a>, and we tend to see <a href="http://books.google.com.au/books?id=PY2BPwAACAAJ&dq=health%20and%20the%20good%20society">health as an individual responsibility</a>.</p>
<h2>Benefits and harms</h2>
<p>Moral obligation is the territory of ethics. So how should we think about the ethics of over-diagnosis in healthy people? </p>
<p>We need to start by weighing benefits against harms, but this is harder than it seems. </p>
<p>The benefits of tests and treatments are often overstated (so straight-talking interpretations <a href="http://www.thennt.com/">like these </a> are invaluable). Evidence is contested, uncertain and incomplete. Harms, in particular, are under-studied, and they’re not only physical. </p>
<p>If we are diagnosed (say, with cancer), we see ourselves differently. And a diagnosis can affect future generations. A cancer diagnosis in a parent can mean their child is declared <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1467-8519.2010.01826.x/abstract">“high risk” for developing cancer</a>, potentially changing his or her medical care, insurance status, and self-concept for life. </p>
<p>Sometimes doctors or policymakers impose these harms on us, but not always. If patients demand tests or treatments, clinicians must trade-off possible harms against their duty to respect the choices and goals that matter to us. When decision-makers try to reduce harms by limiting services, they are often met with <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2837498/">community outrage</a>. </p>
<p>This passion is understandable. Unlike my friend’s dad, most over-diagnosed and over-treated people falsely believe they were saved from death by timely intervention. So it makes sense that they would altruistically defend others’ right to be saved. </p>
<h2>Reimagining society</h2>
<p>We’re all in this mess together: trying to be good citizens, control the future, and wrestle with the uncertainty of science. It’s a difficult challenge, but it’s not impossible. </p>
<p>In 2007 in New Zealand, <a href="http://www.ncbi.nlm.nih.gov/pubmed/17931738">researchers gathered</a> 11 women aged 40 to 49 together to consider the evidence on mammographic breast cancer screening in women their age. At the beginning, all 11 women supported screening. After two days of briefing and deliberation, ten out of 11 were against. We can’t replicate this process for everyone and every test, but it shows the power of good information and reasoned debate. </p>
<p>So what <em>should</em> we do? It depends on the disease and the treatment, and so on the evidence, however uncertain. But it also depends on our vision of a good society. </p>
<p>Over-diagnosis and over-treatment have arisen mostly from a high-tech chase after ever-more-finely-dissected risks in healthy individuals. There’s increasing concern that this chase is doing little for our health, and that the good it does is at the expense of people like my friend’s dad. </p>
<p>It’s not just these active harms we should worry about. We should also be concerned about the opportunity costs. We’ve known for decades that the best way to improve health is to <a href="http://www.who.int/social_determinants/thecommission/finalreport/en/index.html">improve the basics</a>, like the food supply, the built environment, and the fairness of our social and economic systems. Changes like these are good for everyone’s health, and especially for the health of the least well off. </p>
<p>And such changes can only be achieved through collective effort. Perhaps the solution to over-diagnosis and over-treatment includes changing the way we think about ourselves: less as individual disease time-bombs, and more as members of a community, with a shared responsibility to work together to make it easier for everyone to be healthy. </p>
<p><em>Have you or someone you know been over-diagnosed? To share your story, <a href="mailto:reema.rattan@theconversation.edu.au">email</a> the series editor.</em></p>
<p><em>This is part eight of our series on over-diagnosis, click on the links below to read other articles:</em></p>
<p><em><strong>Part one:</strong> <a href="https://theconversation.com/preventing-over-diagnosis-how-to-stop-harming-the-healthy-8569">Preventing over-diagnosis: how to stop harming the healthy</a></em></p>
<p><em><strong>Part two:</strong> <a href="https://theconversation.com/over-diagnosis-and-breast-cancer-screening-a-case-study-7396">Over-diagnosis and breast cancer screening: a case study</a></em></p>
<p><em><strong>Part three:</strong> <a href="https://theconversation.com/the-perils-of-pre-diseases-forgetfulness-mild-cognitive-impairment-and-pre-dementia-8702">The perils of pre-diseases: forgetfulness, mild cognitive impairment and pre-dementia</a></em></p>
<p><em><strong>Part four:</strong> <a href="https://theconversation.com/how-genetic-testing-is-swelling-the-ranks-of-the-worried-well-9080">How genetic testing is swelling the ranks of the ‘worried well’</a></em></p>
<p><em><strong>Part five:</strong> <a href="https://theconversation.com/psa-screening-and-prostate-cancer-over-diagnosis-8568">PSA screening and prostate cancer over-diagnosis</a></em></p>
<p><em><strong>Part six:</strong> <a href="https://theconversation.com/over-diagnosis-the-view-from-inside-primary-care-8889%5D">Over-diagnosis: the view from inside primary care</a></em></p>
<p><em><strong>Part seven:</strong> <a href="https://theconversation.com/moving-the-diagnostic-goalposts-medicalising-adhd-8675">Moving the diagnostic goalposts: medicalising ADHD</a></em></p>
<p><em><strong>Part nine:</strong> <a href="https://theconversation.com/ending-over-diagnosis-how-to-help-without-harming-9633">Ending over-diagnosis: how to help without harming</a></em></p><img src="https://counter.theconversation.com/content/9054/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stacy M. Carter receives funding from NHMRC.</span></em></p>OVERDIAGNOSIS EPIDEMIC – Today, Stacy Carter presents a philosophical view of over-diagnosis and what can be done to change how things stand. Recently a friend told me a story about her dad. Fit and well…Stacy Carter, NHMRC Career Development Fellow, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/86332012-08-09T20:41:50Z2012-08-09T20:41:50ZGiving men choice: the case for routine prostate cancer screening<figure><img src="https://images.theconversation.com/files/14103/original/63fmqrh8-1344492777.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Should a faceless committee decide whether men should have treatment?</span> <span class="attribution"><span class="source">Meeting(green) from www.shutterstock.com</span></span></figcaption></figure><p>Prostate specific antigen (PSA) is a common blood test used by doctors to assess whether an individual has prostate cancer. It also predicts the risk of developing prostate cancer sometime in the future. It’s a good blood test but not a perfect one and the risk of cancer does increase with increasing levels of PSA in the blood tested.</p>
<p>Doctors have improved the accuracy of the test by also looking at the rate the PSA rises every year, by modifying the interpretation of the results in accordance with the age of the patient, and measuring additional modifications of PSA. </p>
<p>The test is usually performed in conjunction with a digital rectal examination, and if the doctor feels the risk of cancer is sufficiently high, a recommendation may be made to visit a specialist urologist and to consider a prostate biopsy, which is the only way cancer can be formally diagnosed.</p>
<p>Some men won’t benefit from a blood test to screen for prostate cancer – those with less than ten years left to live, for instance, or men under 40 years old (because prostate cancer is extraordinarily rare for them). But for a man in his 40s, a single blood test can help predict the risk of both getting and dying of prostate cancer. And it can <a href="http://www.ncbi.nlm.nih.gov/pubmed/21862205">help doctors decide</a> how closely he should be monitored.</p>
<p>Trials have shown a reduced likelihood of death from prostate cancer because of PSA testing for men between 50 and 70 years old with a greater than ten-year life expectancy. This is why PSA testing must continue to be available and offered to men in the appropriate age group.</p>
<p>But before I talk about the evidence for PSA screening, let me correct an <a href="http://www.theage.com.au/national/cancer-specialist-slams-prostate-spin-for-cash-20120731-23d6y.html">offensive allegation published in the press last week</a> – that surgeons recommend surgery for commercial gain.</p>
<p>All doctors are patient advocates and would never recommend a course of action unless they firmly believed that it was in their patients’ best interests. This is exactly why 42% of men diagnosed in Victoria with low-risk prostate cancer are managed with surveillance. They are monitored and treated only if the disease worsens. This course of action demonstrates that urologists are not in a hurry to operate on those who won’t benefit. It’s also the formal position of our <a href="http://www.usanz.org.au/">professional society</a>.</p>
<p>Indeed, urologists are only likely to suggest treatment for men with higher-risk prostate cancer where the survival benefit of surgery over observation has been demonstrated.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/14093/original/j69ygszc-1344491575.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/14093/original/j69ygszc-1344491575.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/14093/original/j69ygszc-1344491575.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/14093/original/j69ygszc-1344491575.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/14093/original/j69ygszc-1344491575.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1130&fit=crop&dpr=1 754w, https://images.theconversation.com/files/14093/original/j69ygszc-1344491575.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1130&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/14093/original/j69ygszc-1344491575.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1130&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">This blood test can help predict the risk of both getting and dying of prostate cancer for men over the age of 40.</span>
<span class="attribution"><span class="source">Monkey Business Images/www.shutterstock.com</span></span>
</figcaption>
</figure>
<h2>Evidence for PSA’s effectiveness</h2>
<p>Let’s start by looking at <a href="http://www.cancervic.org.au/about-our-research/registry-statistics/canstats">Cancer Council Victoria figures</a>. The five-year survival of a man diagnosed with prostate cancer in the late 1980s, when PSA testing was first introduced, was 57%. It’s now 91%, which is a massive improvement. While treatment has also got better during that time, some of the improvement has clearly been the result of PSA-based testing and early detection.</p>
<p>What’s more, a European <a href="http://www.ncbi.nlm.nih.gov/pubmed/19660851">study of PSA screening</a> (ERSPC) has shown a 31% reduction in the risk of dying from prostate cancer over nine years in men who were tested. In the <a href="http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045%2810%2970146-7/abstract">Swedish arm of this study</a>, which followed-up participants for 14 years, the reduction in the prostate cancer death rate was 44%.</p>
<p>The American PLCO trial didn’t show a difference in survival between screened and control groups. But it had numerous flaws, including the fact that over half the men who were not supposed to be tested actually were. So it’s hardly surprising that a difference between the tested and control groups was not detected.</p>
<p>Urologists often recommend conservative management of prostate cancer. Two studies – the Scandinavian prostate cancer group <a href="Vickers%20A%20,%20Bennette%20C%20,%20Steineck%20G%20et%20al.,%20Individualized%20estimation%20of%20the%20benefit%20of%20radical%20prostatectomy%20from%20the%20Scandinavian%20prostate%20Cancer%20group%20randomized%20trial%20Eur%20Urol%202012">(SPCG-4) randomized trial</a> and the <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1113162">prostate intervention versus observation trial (PIVOT)</a> – have clearly shown that, over ten years, men with low-risk prostate cancer may not benefit from surgery, but younger men with larger or higher-grade cancers definitely benefit.</p>
<h2>Helping decide</h2>
<p>In those with an abnormal blood test, a subsequent biopsy will provide valuable information that can help doctors decide if their patient falls into the risk group that benefits from treatment. Without the blood test, the degree of risk will not be known, and men will run the risk of a higher chance of dying from prostate cancer.</p>
<p>Surgery can cause side-effects, such as urinary leakage or erectile dysfunction, in a small number of men, and that has a negative effect on quality of life. But it’s important to note that many men diagnosed with prostate cancer already have pre-existing age-related erectile dysfunction – and many are not bothered by this potential side-effect.</p>
<p>Nonetheless, it’s important that doctors have a frank and open discussion about such side-effects with patients and their partners so that people can make informed decisions about the benefits and harms of their treatment.</p>
<h2>And consider this:</h2>
<p>Does the public want a faceless committee telling them they can’t have PSA-based testing? A committee that tells them it’s better not to know and to bury their heads in the sand? Men have the right to make decisions about their own lives.</p>
<p>As a male in his fifties, I want the right to be tested, to have a cancer detected early and to make my own decision about whether I feel the risks posed by treatment outweigh the risks of the disease. I don’t want a faceless committee deciding on my behalf that they don’t think the risks of treatment are worth taking, when it has the potential to save my life. I can make that decision for myself with the help of my doctor and medical specialists.
<br></p>
<p><em>Read the case <a href="https://theconversation.com/more-harm-than-good-rethinking-routine-prostate-cancer-screening-8612">against PSA testing</a></em></p><img src="https://counter.theconversation.com/content/8633/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mark Frydenberg receives funding from Victorian Cancer Agency .$2M Grant into prostate cancer research - CAPTIV collaboration grant. He is affiliated with Chairman , uro-oncology section of the Urological Society of Australia and New Zealand </span></em></p>Prostate specific antigen (PSA) is a common blood test used by doctors to assess whether an individual has prostate cancer. It also predicts the risk of developing prostate cancer sometime in the future…Mark Frydenberg, Head of Urology at Monash Medical Centre and Associate Professor of Surgery, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/86122012-08-09T20:41:47Z2012-08-09T20:41:47ZMore harm than good: rethinking routine prostate cancer screening<figure><img src="https://images.theconversation.com/files/14091/original/cpj3jscc-1344491501.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A diagnosis of early prostate cancer may end up doing more harm than good.</span> <span class="attribution"><span class="source">Medical Office picture from Shutterstock</span></span></figcaption></figure><p>My offer for a public debate was accepted after I <a href="http://www.heraldsun.com.au/opinion/baby-boomers-the-real-concern-in-fight-against-prostate-cancer/story-e6frfhqf-1226114840059%20and%20http://www.heraldsun.com.au/opinion/testing-war-on-early-prostate-cancer-may-be-dark-age-idea/story-e6frfhqf-1226162443052">co-published opposing viewpoints</a> about the high rates of over-diagnosis and over-treatment of early stage prostate cancer with leading urologist Professor Tony Costello in a Melbourne newspaper last year.</p>
<p>The debate took place at a Melbourne conference on prostate cancer last week. It received wide coverage in newspapers - <a href="http://www.theage.com.au/national/cancer-specialist-slams-prostate-spin-for-cash-20120731-23d6y.html">here</a>, <a href="http://www.theage.com.au/national/cancer-treatment-hijacking-a-fallacy-urologists-20120801-23fn2.html?skin=text-only">here</a> and <a href="http://www.smh.com.au/national/cancer-treatment-hijacking-a-fallacy-urologists-20120801-23fn2.html">here</a>, <a href="http://www.sbs.com.au/news/video/2262636759/Specialist-sparks-prostate-test-controversy">television</a> radio, and <a href="http://www.oncologyupdate.com.au/getmedia/5a5e93e3-8c1d-4ba5-a293-78bcab0fc986/onco_03_08_12.aspx?ext=.pdf&amp;nodeid=2696703&amp;utm_source=SilverpopMailing&amp;utm_medium=email&amp;utm_campaign=Oncology%20Newsletter%20MREC%20-%20send%20-%3E%203/08/2012%203:09:40%20PM&amp;utm_content">online</a>. All of this is useful and important because it helps stimulate the very important debate about widespread PSA screening.</p>
<p>Prostate specific antigen (PSA) is an enzyme secreted in large amounts by normal as well as cancerous prostate cells. Only small amounts of PSA leak into circulation from a normal prostate, but this increases with any prostatic disease, benign or malignant. </p>
<p>PSA concentration is expressed as a number and its discovery in 1983 led to it being used as a screening blood test for early prostate cancer. A level below four is considered normal and men with abnormal results are usually sent for biopsies. It has been widely performed in Australian men for over ten years as part of a general health check but its ability to save lives is now being assessed and tested.</p>
<h2>Ideal health</h2>
<p>For years now, family physicians, the <a href="http://www.usanz.org.au/">Urological Society of Australia and New Zealand</a> and spokespeople for treatment advocacy groups, such as the <a href="http://www.prostate.org.au/articleLive/">Prostate Cancer Foundation of Australia</a> have been telling men to have blood tests with a PSA as part of their regular health check up because early diagnosis may save their life.</p>
<p>The constant message is that men need to look closely for any signs of early prostate cancer by having a PSA and a digital rectal examination. This is because, up until recently, our belief and practice was that if the PSA was high, the patient should be referred to a urologist for a transrectal biopsy (a large and very unpleasant needle, inserted under local anaesthetic through the wall of the rectum up to 24 times, just above the anus). And if this biopsy showed prostate cancer, the man would usually be offered immediate radical treatment with surgery or radiation to cure the cancer.</p>
<p>But we’ve long known that prostate cancer is a disease that men can harbour for most of their lives without knowing. It is <a href="http://www.ncbi.nlm.nih.gov/pubmed/16885911">very commonly</a> found during postmortem (even in very young men). We also now know that PSA is highly unreliable as a predictor of cancer.</p>
<h2>False results and consequences</h2>
<p>A <a href="http://www.nejm.org/doi/full/10.1056/nejmoa031918">major prospective prostate cancer trial</a> actually found cancer in 15% of men with normal direct rectal examination results and PSA of less than the “normal” concentration of four (considered as the cut-off between “normal” and “abnormal”). It also found cancer in 25% of the participants with levels between three and four. This is similar to the rate of 25% of biopsies showing prostate cancers in men with so-called abnormal PSA. So you have an almost equal chance of having cancer found irrespective if your PSA is normal or abnormal!</p>
<p>Indeed, the false-positive and false-negative rates of PSA alone make it a useless screening test. Our current rate of PSA testing uptake threatens to diagnose up to 60,000 men a year in Australia, 25 times the number destined to die from it.</p>
<p>Prostate cancer appears to be two diseases, an uncommon one that can kill you (at an average age of 81 years) and a very common one that poses no risks. Even though prostate cancer is a leading cause of male mortality in Australia (with over 2000 deaths a year), it’s never been known whether radical treatment of early stage disease can alter the natural history of those cancers biologically destined to kill the patient or whether it only “cures” those cancers destined to remain indolent for many decades and not affect lifespan.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/14099/original/ysk6vygz-1344492161.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/14099/original/ysk6vygz-1344492161.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=836&fit=crop&dpr=1 600w, https://images.theconversation.com/files/14099/original/ysk6vygz-1344492161.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=836&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/14099/original/ysk6vygz-1344492161.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=836&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/14099/original/ysk6vygz-1344492161.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1050&fit=crop&dpr=1 754w, https://images.theconversation.com/files/14099/original/ysk6vygz-1344492161.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1050&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/14099/original/ysk6vygz-1344492161.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1050&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Man should be asked to provide informed consent for PSA tests.</span>
<span class="attribution"><span class="source">Man choosing his way from www.shutterstock.com</span></span>
</figcaption>
</figure>
<p>Some believe that the term “early stage prostate cancer” is misleading and a misnomer for most men, similar to the condition called chronic lymphocytic leukaemia, which sounds frightening but is usually a very indolent disease that lies dormant for decades and rarely ever needs treatment.</p>
<h2>All harm, no help?</h2>
<p>Recent evidence from several high-quality prospectively randomised clinical trials have shown two stunning results. The first two (<a href="http://www.nejm.org/doi/full/10.1056/NEJMoa0810696">here</a> and <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1113135">here</a>) showed that regular screening with PSA and treatment of detected cancers produces no overall survival benefit for the treated group, and only a tiny reduction in deaths due to prostate cancer. The <a href="http://www.nejm.org/doi/pdf/10.1056/NEJMoa1113162">third</a> showed that radical treatment with surgery or radiation therapy provides no benefit for the vast majority of men who have been treated this way and causes very serious and long-lasting side-effects.</p>
<p>PSA screening of the male Australian population probably doesn’t save any lives at all, but leads to a lot of over-diagnosis of a condition called early prostate cancer that will not shorten the lives of the overwhelming majority of men. This creates serious harms, including toxicities from unnecessary and radical treatments and imposes vast financial and manpower costs on our health system.</p>
<p>The harms come from the transrectal biopsies (pain, infection and haemorrhage), and initial radical treatments. Then, there are penile implants and drugs to treat sexual impotence resulting from treatment and the cost of urethral sphincters (around $20,000 for every initial insertion and then replacement). Add to this the time of physiotherapists and nurses for urinary incontinence and the psychologists for the depression and associated relationship stresses.</p>
<h2>Time to change</h2>
<p>Following an extensive and detailed review of all the literature, an expert team from the <a href="http://www.ahrq.gov/clinic/tp/mgenprcatp.htm">US Preventative Services Taskforce</a> has very recently <a href="http://annals.org/article.aspx?articleid=1033197">issued the lowest possible recommendation</a> for PSA screening because it’s highly likely that its harms significantly outweigh its benefits. And the test has been called a <a href="http://www.nytimes.com/2010/03/10/opinion/10Ablin.html">public health disaster</a> by Dr Richard Ablin, who invented it. I <a href="http://blogs.crikey.com.au/croakey/2010/03/22/psa-screening-is-a-public-health-disaster-says-cancer-doc">clearly concur</a> with him.</p>
<p>It’s time for family physicians to stop doing routine screening PSA tests of Australian men unless patients decide to proceed after being told about the latest research and indicate they understand the potential benefits and harms. Indeed, they should be asked to <a href="http://www.smh.com.au/national/health/doubt-over-the-worth-of-prostate-surgery-20120719-22d51.html">provide informed consent</a>.</p>
<p>For those diagnosed with early prostate cancer, immediate and radical treatment is unnecessary for the vast majority and active surveillance or watchful waiting should be recommended. It’s now reasonable and preferable that all men be offered a second opinion before proceeding to radical treatment for early stage prostate cancer.</p>
<p>As with all advances in medical treatment over the last 350 years, we depend on constant clinical research comparing what we currently do with what we hope may be better by some measurable parameter. When the evidence changes, we must all revise our beliefs and practices.
<br></p>
<p><em>Read the case <a href="https://theconversation.com/giving-men-choice-the-case-for-routine-prostate-cancer-screening-8633">for PSA testing</a></em></p><img src="https://counter.theconversation.com/content/8612/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ian Haines 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>My offer for a public debate was accepted after I co-published opposing viewpoints about the high rates of over-diagnosis and over-treatment of early stage prostate cancer with leading urologist Professor…Ian Haines, Adjunct Clinical Associate Professor & Senior Medical Oncologist and Palliative Care Physician, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.