In the United States, questioning cancer screening is a risky business
Many people in America see health screening as a panacea. Screening, the thinking goes, wards off disease and allows people to stay healthy, perhaps forever. Those who question this fairytale view, as we have just discovered, are considered traitors, or even murderers.
On 18 December 2001, the San Francisco Chronicle published an article about Dusty Baker, manager of the Giants, the city’s baseball team. Baker had just had surgery for prostate cancer. His cancer, said the article, had been picked up after a routine blood test for prostate specific antigen (PSA).
The article quoted a Stanford University urologist as saying that PSA tests had made "a world of difference" in treating prostate cancer because "doctors have been able to catch the tumors early before they have spread." It also stated that Baker’s doctors had chosen surgery over radiotherapy or hormone therapy, since surgery was "the surest way to prevent any return of the disease."
This high profile article, appearing in the paper’s sports section, would have been read by thousands of men. It would have left them with an extremely optimistic picture of the benefits of PSA testing and of prostate surgery.
We wrote a letter to the editor arguing that the Chronicle had failed to reflect the massive controversies surrounding prostate cancer screening and treatment. The Chronicle’s editorial team had never heard about the controversies. This is no surprise given the pro-screening lobby’s dominance of the US media.
Instead of publishing the letter, the editors invited us to write an opinion piece discussing the reasons why men should not be screened. The piece, "Prostate cancer screening—is it worth the pain?" appeared in the paper’s Open Forum section (18 January 2002), which is devoted to personal views, debate, and controversy.
We argued in our piece that the PSA test is unreliable, and that it mostly picks up slow growing tumours that would never have become clinically apparent. We discussed the ways in which picking up such tumours may harm men, given that they are then subjected to cancer treatments that can have serious side effects.
We also explained that doctors still do not know how best to treat prostate cancer. It is our belief, we argued, that a programme to screen healthy men cannot be justified since there is no good evidence that it would change the outcome of the disease.
Within hours of our piece being published, prostate cancer charities, support groups, and urologists around the country had circulated a "Special Alert" by e-mail. This community has huge faith in PSA tests, and it did not care for our opinion. The e-mail, under the header "ATTENTION MEN!!" urged the community to take action.
By the end of the day, accusations, abuse, and personal threats jammed our e-mail inboxes. We were compared to Josef Mengele, and accused of having the future deaths of hundreds of thousands of men on our hands.
Our view, said one particularly angry letter, was "geriatricide in the making." The president and chief executive officer of a major prostate cancer charity said he would be asking "supporters and legislators" to look into our "behavior." Many people wrote to us wishing that we ourselves would get prostate cancer. Others tore apart our credentials, arguing that only urologists were qualified to have an opinion about PSA testing.
We initially attempted to respond to each individual who contacted us, explaining that our opinion was not unique, but was shared by, among others, the US Centers for Disease Control and the US Preventive Services Taskforce. But we were experiencing "saturation tactics"—there were too many people to respond to, and anything we wrote provoked a further round of abuse and accusations.
A member of a prostate cancer listserv advised all members to take two other immediate actions. First, he said, put "continued pressure on the San Francisco Chronicle" to publish material that would "offset the damage" we had caused. The Chronicle has been bombarded with phone calls and e-mails, and says it has never published a more controversial piece.
Second, he said, "Write to their [the authors’] bosses at University of California Davis and the Office of the President. Tell them to fire these imposters. Tell them these folks should be silenced." The chancellor of the University of California and the dean at University of California Davis medical school are now receiving a flood of letters urging disciplinary action against us, and demanding that we are banned from our teaching positions.
What is going on here? Why are these advocates of screening doing all they can to silence our dissenting voices?
One reason is that they have so much invested in believing in the power of screening and treatment. Some of this belief is born out of an understandable fear of a disease that is sometimes fatal, and an intense desire to conquer it. There is a deep wish to believe that the PSA test really does make a "world of difference." In expressing our opinion—that there is no good evidence that mass PSA testing is the right thing to do—we dared to challenge this wishful thinking.
More importantly, we dared to tread on the toes of a powerful pro-screening lobby. In encouraging all healthy men to take a PSA test, this lobby has a major conflict of interest, since it has a financial stake in offering investigations and treatments for prostate cancer. Even some of the charity groups in this lobby have a conflict, since they receive funds from manufacturers of prostate cancer treatments or have ties with the American Urological Association. The backlash against our piece smells to us like a battle to hold on to power and, dare we say it, money.
With the widespread belief in America that every man should know his PSA, a belief driven by politics and not evidence, we fear that sceptical voices like ours will always be drowned out.
deputy editor, Western Journal of Medicine, Oakland, California
editor, Western Journal of Medicine, Oakland, California
Competing interests: The authors have received a grant from the Centers for Disease Control to devise a teaching tool for primary care physicians on prostate cancer screening.
BMJ 324 (7332): 255a Data Supplement - Prostate Debate
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