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The East African : Apr 27th 2015
The EastAfrican OUTLOOK APRIL 25 - MAY 1, 2015 the prostate cancer test — scientists between 40 and 45 years should be confined to those deemed to be at high risk. High risk individuals are men with a family history of prostate cancer, those diagnosed with urinary tract infections and those experiencing sexual dysfunction, weight loss or suffering bone pain. Dr Kohli warned that over-di- Xxxxxxxxxxxxxxxxxxx. Pic: File PROSTATE CANCER PERCENTAGE DEATH RATE PER 100,000 POPULATION Uganda A patient in the consultation room. Pic: File Burundi Kenya Rwanda Tanzania = 10,000 Men who undergo PSA screening could potentially increase their risk of harm.” relatively higher value on the risk of a false positive result, unnecessary biopsies, over-diagnosis of prostate cancer and harms associated with unnecessary treatment,” the scientists say of men aged between 55 and 69 years, who are not deemed to be at high risk. Instead, they say the risks and benefits of PSA screening and its potential consequences should be discussed with each patient in the above age category, in the context of his preferences. “Men who place a high value on a small potential reduction in mortal- 12.4 pc 7.3 pc 6.7 pc 6.2 pc 3.9 pc Source: WHO ity and are less concerned with undesirable consequences may choose to be screened,” the scientists say. A no-PSA-test policy is also rec- ommended for men aged 70 and above. The scientists say the recommendation “reflects the lower life expectancy and the lack of evidence for the benefit of screening in this age group as well as the evidence of harm.” Dr Ruchika Kohli, country direc- tor of Pathologists Lancet Kenya (PSK), concurred with the recommendations of the task force, saying early screening for men aged agnosis, for example, can result in overtreatment, which can cause unnecessary complications and harmful side effects, among them urinary incontinence (loss of bladder control), bowel incontinence (loss of bowel control) and other infections. “Over-diagnosis can also cause undue anxiety to the patient and his family, given the challenges associated with cancer,” the pathologist added. But there is hope, as scientists are working round the clock to improve the PSA test to enable it to distinguish cancer from benign conditions. DRE radiology In the meantime, Dr Kohli said, PSA should not be used in isolation as a screening test in the general population, but in conjunction with DRE radiology. Due to the challenges facing PSA, the task force recommended future research on finding alternatives to the test for prostate cancer screening and reducing inappropriate PSA testing. “Future research should also de- velop methods to identify the subset of men with prostate cancer in whom clinically relevant disease would develop (in the absence of treatment),” the researchers say. The scientists identify magnetic resonance imaging and clinical decision rules as promising approaches to improving the risk: Benefit ratio of screening, but say that the methods need to be tested more on rigorous randomised trials. The task force also recommends investigations into the benefits of PSA screening among men with a family history of prostate cancer or men of the black race, saying it would be helpful to determine whether screening in these highrisk populations is warranted. PROSTATE CANCER IN BRIEF Prostate cancer is a disease that affects men. Cancer normally begins to grow in the prostate — a gland in the male reproductive system. The prostate gland produces a protein called PSA (prostate-specific antigen). The PSA helps keep the semen in its liquid state. Some of the PSA normally escapes into the bloodstream. A man’s PSA level can be measured by checking his blood. If the level is high, it could be an indication of prostate cancer. High PSA levels in the blood may not be harmful to a man, but can be an indication that something is wrong in the prostate. Male hormones normally affect the growth of the prostate and also how much PSA the prostate produces. Medications, for example, aimed at altering male hormone level may affect PSA levels. SYMPTOMS OF PROSTATE CANCER One or more of the following occur: One urinates more often. One gets up at night more often to urinate. One may find it hard to start urinating. One may find it hard to keep urinating once he has started. Having blood in the urine. Urination being painful. Experiencing sexual dysfunction. If prostate cancer is at an advanced stage, the following symptoms show: Bone pain, often in the spine (vertebrae), pelvis, or ribs. Leg weakness (if cancer has spread to the spine and compressed the spinal cord). Urinary incontinence (if cancer has spread to the spine and compressed the spinal cord). Faecal incontinence (if cancer has spread to the spine and compressed the spinal cord). CAUSES OF PROSTATE CANCER Age Age is considered the primary risk factor. The older the man, the higher the risk. Prostate cancer is normally rare among men under the age of 45, but much more common after the age of 50. Genetics Studies show that prostate cancer is higher among black men than white men. In addition, a man whose brother or father has prostate cancer has a higher risk of developing it than other men. 33 docto≥s like quantifying tests, instead of good ca≥e all in the name of good and equitable health care, a laudable goal. But if you reach 50 years and I cannot persuade you to undergo the colonoscopy or mammogram you really don’t want, am I a bad doctor? If you reach 85 and I persuade you to take enough medication to normalise your blood pressure, am I a good one? A cadre of test sceptics at Dartmouth Medical School specialise in critically examining our test-based ap- proach to well adult care. If you are confused about mammography, colonoscopy or the PSA test for prostate cancer, these folks deserve much of the blame: They have repeatedly demonstrated that these tests and many others do not necessarily ameliorate a healthy person’s health, any more than standardised testing in grade school improves a child’s intellect. Dr H. Gilbert Welch, Vermont physician who is part of the Dartmouth group, has a new book that may serve as the test sceptic’s manifesto and bible. Its title, Less Medicine, More Health, sums up his trenchant, point-by-point critique of test-based health care and quality control. In medicine, “true quality is extremely hard to measure,” Welch writes, “What is easy to measure is whether doctors do things.” Only doing things like ordering tests generates data. Deciding not to do things and let well enough alone generates nothing tangible, no numbers or dollar amounts to measure or track over time. Welch points out that doc- tors get to become doctors because they are good with tests, and know instinctively how to behave in a test-focused universe. Rate them by how many tests they order, and they will order in profusion, often more than the guidelines suggest. They will do fine on assessments of their quality, but patients may not do so well. Even perfectly safe tests that are incapable of doing their own damage may, given enough weight, trigger catastrophe. Yes, little blood pressure cuff over there in the corner, that means you. The link between high blood pressure and disease is incontrovertible, and the drugs used to control blood pressure are among the cheapest and safest around. Even so, systems that rate doctors by how well their patients’ blood pressure is managed are likely to invite trouble. Doctors rewarded for treating aggressively are likely to keep doing so even when the benefits begin to morph into harm. Children go to school to learn. Adults go to the doctor. Why? If they are sick, to get better, certainly. But for the average healthy, happy adult, let’s be honest: We really haven’t figured out why you are in the waiting room. And so we offer a luxuriant profusion of tests.
Apr 19th 2015
May 3rd 2015