Healthcare must engage in a wider discussion about preventive medicine
by Alan Cassels
• “Preventive medicine displays all three elements of arrogance…Aggressively assertive…Presumptuous…Overbearing.”
Dr. David Sackett wrote those words over a decade ago in a neat little column in the Canadian Medical Association Journal. He was, in this case, talking about hormone replacement therapy, after the publication of one of the world’s largest studies in preventive healthcare. The results of the Women’s Health Initiative showed that giving estrogen and progestin to healthy women going through menopause, on the assumption that this was vital preventive medicine, did not protect them from cardiovascular disease. In fact, it increased rates of some forms of cancer, heart attacks, blood clots and strokes. In trying to preserve and protect health, the recommended therapies were harming women. On a massive scale, I should add.
By way of background, I need to tell you it took many years – and probably cost many thousands of lives – before that study was launched. It took lobbying by independent women’s health advocates years to convince the research world they needed better proof that women’s lives were being improved by taking hormone replacement every day after they reached menopause. The Women’s Health Initiative, a high-quality randomized trial, was eventually funded and ran for seven years. The results dropped like a bombshell on the medical world and was, as some said, “the day the music died” for hormone replacement therapy.
For me, Sackett scored a direct hit with his words and reminded me that humility is a human virtue often in short supply in the medical world. He was right to say we need to seriously rethink the “arrogance” of preventive medicine, which aggressively asserts itself into peoples’ lives, rudely claiming people will only benefit from it. It is also “presumptuous,” assuming with an overweening confidence it will do more good than harm, even when there is insufficient evidence to defend that confidence. And quoting Sackett, “preventive medicine is “overbearing,” attacking those who question the value of its recommendations.”
Well, let me tell you, as someone who bears some scars over the years from calling out preventive medicine’s arrogance, last month provided me a little salve for the soul with new research around the way we try to prevent prostate cancer. For over two decades, men have been told that, once reaching the age of 50, they needed to get a PSA test. After all, wouldn’t you want to do something so simple if it protected you from a horrible death from prostate cancer? No doubt, we have all lost fathers and brothers from this disease, which is horrible, yet thankfully much more rare than we are led to believe.
A study published in the New England Journal of Medicine examined more than 1,600 men in the UK, aged 50 to 69, diagnosed with localized prostate cancer. This is typically diagnosed with a “high” PSA or prostate specific antigen reading that is obtained from a simple blood test. While many other things besides prostate cancer can cause a higher than normal PSA reading, it is usually a sign that something needs to be done. The big question is if you’re diagnosed with prostate cancer, should you get surgery, drugs or just ‘do nothing’ and wait and see what happens?
The study divided the men into three groups of roughly equal size: the first group were given chemotherapy, the second had surgery and the third were given ‘active monitoring,’ which is to say the last group essentially had no treatment whatsoever.
What the ProtectT trial – stands for Prostate Testing for Cancer and Treatment – found after following these three groups of men for 10 years was that 99% of them were still alive, regardless of which path they were on. Most surprising? The men who were treated – with surgery and chemotherapy – didn’t live any longer than those who weren’t. And they didn’t live any healthier either, as some of those treated faced the adverse effects of the treatment.
For several decades, PSA testing has been aggressively recommended for middle-aged men. It was often ordered by doctors by a mere check mark on a lab requisition, and some men didn’t even know their blood was being tested for prostate cancer. If that doesn’t correspond to Sackett’s “aggressively assertive” description of preventive medicine, I don’t know what does. And people like me, who questioned the advice that healthy, symptom-free men should be given a PSA test, continued to be attacked, often in an overbearing manner, told we were hurting men by making men hesitate to get the test.
Thankfully, due to this research, physicians are more likely to leave our prostates alone and stop poking and prodding men who have no symptoms. Which reminds me, everyone knows that urology is a great source of medical humour. For example:
Q: Why did the physician use two fingers to do a digital rectal exam?
A: He wanted to get a second opinion.
Ba dump, bump.
Men around the world are now rejoicing because of other prostate-related news that came out this summer. Like the PSA test, the research results of a large study of the dreaded DRE (Digital Rectal Exam), promoted as another way to hunt for early signs of prostate cancer, found it was probably useless and should be abandoned. Obviously, for men at greater risk – those with a close family history of prostate cancer, or who have prostate symptoms –it might make sense for the DRE or the PSA, as they might have a higher chance of benefit. But for otherwise healthy men? It’s time to show some humility.
While this new research on screening for prostate cancer adds to our collective thinking of the problems of overdiagnosis, it also demands us to engage in a wider discussion about preventative healthcare and how much energy we, as a society, keep expending trying to cheat death.
The danger of preventative medicine is not just the willy-nilly nature of how it is used, frequently in the absence of evidence, it’s the way it’s used as a justification for all kinds of poking and prodding of perfectly healthy people. It’s not like all this vigilance about disease makes us feel any healthier. As Dr. Iona Heath once wrote in the British Medical Journal: “It seems that the more people are exposed to doctors and contemporary health care, including the rhetoric of preventive care, the sicker they feel.”
Several years ago, I had the chance to spend a day interviewing the late Dr. David Sackett, who was deeply involved in the early creation of the Cochrane Collaboration and a strong early proponent of proper use of randomized trials to decide important questions in healthcare. (Note to file: the ProtectT trial and the Women’s Health Initiative were both randomized trials.) I travelled to his home at Irish Lake, a few hours north of Toronto and found a big barrel-chested tower of a man. Nearing 80, and still full of verve, the man considered the father of evidence-based medicine displayed none of the arrogance that he railed against in his attack on the arrogance of preventive healthcare.
Now that it seems pretty clear men won’t live any longer with a PSA test, and that their lives are unlikely to be healthier – due to the impotence and incontinence related to the surgery and chemotherapy – they may choose not to pay these costs.
In his book Overdiagnosed, Gilbert Welch called PSA screening the “Poster Child” for overdiagnosis, but I would push that paradigm a bit further. I’d say that PSA testing and early prostate cancer treatment could be called the “Poster Child” of arrogant, preventative medicine, demonstrating how deeply we are capable of misleading ourselves into thinking we’re doing good, while doing harm.
With thousands of men in Canada, and over a million in the US, made incontinent or impotent because of PSA testing and treatment, it’s time for a little bit of humility. And unless we reject the arrogance of preventive medicine, people will continue to be harmed by its overly assertive, presumptuous and overbearing manners.
Alan Cassels is a drug policy researcher in Victoria and the author of Seeking Sickness (about medical screening), which includes a chapter on PSA testing. He spent the day with David Sackett on Halloween in 2012.