Friday, September 25, 2009

Irresponsible prostate testing proposal ignores risk of harm to men

Testing saves less than one life in a thousand and has its own perils. The great majority of men who get chopped about as a result would have been OK if left alone

In 2003, Professor Alan Coates, then 58 and head of Cancer Council Australia, admitted he had not had, and wasn't planning to have, a test to see if he had prostate cancer. Wayne Swan, a prostate cancer survivor, called his statement "public policy vandalism".

Coates was not a lone heretic. While it would be rare to find a smoker working in cancer control, or any woman in the same field who had not had a Pap smear, many men who know much about the evidence on whether prostate testing saves lives have not been tested themselves. A study in 2002 of male GPs in Victoria aged over 48 found less than half had been tested; many physicians choose to remain ignorant about whether they have the disease. What do they know that the Urological Society of Australia and New Zealand does not?

The society has recommended 40 as the age for men to consider having their first prostate-specific antigen test, or PSA, and for those in the top half of PSA levels to be considered higher risk and "monitored closely". Those with lower levels could have less frequent testing.

Earlier this year, results from a European trial involving 160,000 men aged 55-69 were published in the New England Journal of Medicine. Only some were given PSA tests. It showed that if you screen 1000 men, you will find 82 cases, and if you follow these men for an average of nine years, there will be 2.94 deaths. In 1000 unscreened men over the same period, 48 cases of prostate cancer will come to light by men presenting symptoms to their doctor. There will be 3.65 deaths. The difference between the two means, in short, testing saves 0.71 deaths per 1000 men over nine years.

Prostate cancer is a disease from which you are more likely to die very late in life. For elderly men - those over 84 - the death rate is 767 per 100,000 men, while for those aged 40 to 44 it is 0.3. This means there will be one death per year from prostate cancer in every 330,000 men aged 40-44, an age group the Urological Society now believes should be tested. The odds of any one man this age dying from the disease are nearly twice as poor as winning first prize in a lottery with 200,000 tickets.

By doing a PSA test on all these men and applying the proposed threshold, hundreds of thousands of men will now be considered higher risk and monitored closely for prostate cancer.

Autopsy studies show you can find prostate cancer in up to one-third of men of this age if you look hard enough for it. By finding all these cancers there is the potential for harm on a massive scale, because there are real and frequent risks associated with treatments for prostate cancer.

Getting a test result is just the beginning. When cancer is suspected following a PSA test, we know in Australia it is aggressively treated in younger men. The European trial showed that to save just one life from screening, an additional 48 men would need to be treated, and it was using a much higher threshold than is now proposed here. In other words, to save one life, 48 men would be treated who would not have died from the disease.

They are treated because our science is not advanced enough to know which of 49 men's lives will be saved by having their prostates removed. And the treatment is far from benign. According to a review last year by the US Preventive Services Taskforce, one year after surgically removing the prostate gland, 20 to 70 per cent of men have reduced erectile function, and 15 to 50 per cent have persisting urinary problems.

There is no evidence from trials to support the proposed new strategy, nor has the Urological Society commented on its cost-effectiveness. What are the costs of close monitoring of half the nation's men aged in their 40s? What health-care services are going to be cut to cover the additional costs? Or must the health budget be increased?

To make such recommendations without considering the potential to do harm to men and to the health-care budget is irresponsible. Furthermore, urologists and the companies selling PSA tests stand to benefit from concern among men to be tested. In a recent letter to the Herald a man who had undergone prostate removal said he paid $15,000. These facts are almost always absent from the advice given to men by the few agencies which are aggressively promoting screening.


Quackery at the University of Toronto

Three weeks ago or so, I expressed dismay at what I perceived as an autism quackfest being held at the University of Toronto. Worse, that quackfest had been partially funded by a grant from a very prestigious children's charity, The SickKids Foundation, which in response to complaints about its sponsoring the autism quackfest known as AutismOne/Autism Canada 2009 Conference, wrote a limp and pusillanimous form e-mail that it sent to everyone who complained. It was truly disappointing to see that an organization that should be supporting science-based research into the treatment of children's cancer and other serious diseases that primarily affect children would be lending its money, name, and prestige to autism quackery, including anti-vaccine loons, homeopaths, and "energy medicine" practitioners.

One salutary effect of my posts was that the University of Toronto's Dalla Lana School of Public Health. which had been previously listed on the early advertisements as a co-sponsor of this event, apparently told AutismOne to stop using its name. Certainly, more recent iterations of the Autism Canada website and advertisements show no such affiliation anymore.

I still find it truly depressing that the SickKids Foundation sees nothing wrong with funding this nonsense, and I sincerely hope that this is an older brochure and that the Dalla Lana School of Public Health has made it very plain that it does not support autism quackery.

More here

‘Egg whisk’ pioneered by doctor helps pump blood during heart surgery

A miniature “egg whisk” that rotates faster than a high-speed food blender has been pioneered by a British doctor to help the heart to pump blood round the body during life-saving surgery. The ground-breaking procedure, which involves passing the fold-up whisk through the body to a site next to the heart, allows patients with weak hearts to have an artery unblocked without the risk of kidney failure or cardiac arrest.

More than 100,000 patients undergo artery-clearing angioplasty annually, but many remain at high risk of serious complications because of their problems pumping blood. But now Professor Martin Rothman, a cardiologist based at the London Chest Hospital, has completed the first human trials of the revolutionary whisk, which is inserted via a catheter through the groin shortly before the angioplasty takes place.

The procedure, which has not yet been licensed, has proved so successful in patients to date that it was broadcast live yesterday to a key conference in San Francisco attended by 10,000 cardiologists. The whisk, called the Reitan catheter pump, is inserted in a tube via the femoral artery and manoeuvred up to the aorta, where it folds out to form a plastic cage encasing two stainless steel propeller blades of about 8mm in length.

Once switched on — a wire running down the catheter allows it to be powered electrically — the device rotates at up to 12,000rpm, enhancing the pumping action of the heart by drawing blood down from the aorta to the arteries. This keeps vital organs, such as the kidneys, working as the patient undergoes angioplasty.

Professor Rothman told The Times that the device effectively “unloaded the heart”, reducing the risk of heart attack, kidney failure and cardiogenic shock — when reduced blood flow causes multi-organ malfunction. Once the angioplasty is completed, the Reitan catheter pump can be removed.

Professor Rothman said that with up to one in ten patients who need angioplasty being at risk of cardiac and renal failure, the device would bring benefits for thousands of patients every year and even appeared to improve severe kidney problems. He added: “This technology offers real opportunity for sick patients to undergo a very important procedure — patients who, were you to blow a balloon up in their arteries, would otherwise likely be pushed over the edge. “The pump is incredibly powerful — if you stuck it in a bucket of water it looks like the whole thing is boiling. It helps people with heart failure survive this procedure better and with less risk.”

Professor Rothman carried out the first trial after discovering the device, designed by √ėyvind Reitan, a Swedish cardiologist and engineer, a few years ago. To date, the British doctor, who works in Barts and the London NHS Trust, has carried out 17 procedures, with published data on the first ten. While a pump would cost about £1,000, and can be used for only one procedure, the savings of preventing a patient from ending up on kidney dialysis are substantial. Three days on dialysis would cost about £10,000.

For the surgery last night, Professor Rothman operated on a woman, 79, who had blockages in her right coronary artery and proximal left anterior descending artery. As a diabetic with high blood pressure and raised cholesterol, the woman had been refused angioplasty by other cardiologists. She is now back on the ward.

Describing the notion that it might reverse kidney failure as a “Star Trek moment”, Professor Rothman said that his team were examining evidence collated so far. One case involved a woman who was only able to pass 10ml or urine per hour in the two weeks before the operation because of poor kidney function, who passed ten times the amount with the device in place.

“It was a revelation to see that patients who had a chronic or long-term impairment of the kidney could actually have that state reversed using the pump,” he said. “That was amazing. We saw the data and it made a lot of us think again. You think most people who have chronic kidney failure have exactly that. You don’t expect them to impove their function and that’s what we have seen.”

Ellen Mason, a cardiac nurse with the British Heart Foundation, described the work as pioneering. She said: “It is great to see a British cardiologist leading the way in the field of international cardiology. “The application would be in people with cardiogenic shock which is usually fatal, or severe heart failure probably due to a heart attack. The hope is that they would be able to undergo urgent treatment for heart attack, when before it would have been too risky. “The data from these trials will determine whether this will become more widespread in the UK and the rest of the world.”

A representative for Barts and The London NHS Trust, which includes the London Chest Hospital, said that it fully supported Professor Rothman’s work. “The trust is committed to providing first class clinical care to all its patients. Our support of cutting-edge research work such as the Reitan Catheter Pump System, is just one example of our ongoing work to help patients to live better, fuller and longer lives.”


No comments: