Hans so well said, especially, "What makes the policy vulnerable is that it feels less like a confident embrace of modern evidence and more like a holding pattern.", and supports the Imperial College London, "....views of clinicians involved in diagnosing and treating prostate cancer...not routinely captured during the decision-making process." In your words, Hans, coupled with Howard's continued commitment to us, one can no longer claim ignorance of the controversy, for the issue of "bullied acquiescence" written about in the Journal of Clinical Ethics is front and center, RIPE within the profession! To those wo have not shown support for this blog not in the medical field, where else would you learn of research directly bearing on your care?
The strongest possible condemnation should be reserved for things like selling cigarettes in pediatric wards, replacing parachutes with positive thinking, or serving English beer at room temperature and calling it a feature. What England is doing is not madness. It is caution. The real question is whether it is cautious to the point of paralysis.
The devastating critique is not that policymakers are evil, indifferent, or stupid. It is that they remain trapped in a prostate cancer debate that often sounds as though it is still taking place in 1998. Their entire argument rests on a legitimate observation: PSA testing led to overdiagnosis and overtreatment. This is true. Men were diagnosed with cancers that may never have harmed them, and some suffered unnecessary side effects. Nobody disputes this.
The problem is that medicine has not remained frozen in amber while the committee continued studying spreadsheets.
The policy reads like a government document written by people who have become so terrified of treating men unnecessarily that they have become comfortable not finding them at all.
Consider the logic. A 55 year old Black man with a father and brother who had prostate cancer is apparently not high risk enough. A man with a strong family history but no BRCA2 mutation is apparently not high risk enough. But a man who checks a very specific genetic box enters the sacred circle of approved concern. This is precision medicine carried to the point of absurdity.
Imagine applying the same standard elsewhere. "We recognize that your house is on fire, sir. We can see flames emerging from the windows and smoke pouring from the roof. However, our models indicate that only houses with red front doors and Labrador retrievers statistically benefit from immediate firefighting. We are funding a promising study regarding blue doors. Results expected sometime after your living room has collapsed."
The entire exercise reveals a peculiar bureaucratic instinct. When confronted with uncertainty, institutions often conclude that the safest action is inaction. If ten men are harmed by overtreatment, that is measurable and visible. If ten men die because their cancer was never found early enough, that harm is dispersed, delayed, and easier to ignore.
Politically, overtreatment creates victims with names. Undertreatment creates statistics.
The irony is that the very advances designed to solve the old screening problem are largely ignored in the argument. MRI was not part of widespread screening pathways thirty years ago. Active Surveillance was not nearly as accepted. Genetic risk models were primitive. Risk stratification was crude. Yet many of the assumptions driving today's decisions are still built on data from an era when the internet made screeching dial up noises and grown adults believed fax machines represented the future.
Meanwhile, specialists who spend their lives diagnosing prostate cancer increasingly seem to be saying the same thing: perhaps the balance has changed.
When two thirds of practicing urologists disagree with the policy, it may be worth asking whether the people treating the disease know something that the policy model does not.
The most troubling aspect is not the exclusion of average risk men. Reasonable people can debate that. It is the exclusion of groups that almost everyone agrees are at elevated risk. Black men. Men with strong family histories. Men whose risk is obvious without requiring a genetic sequencing report thick enough to stun a badger.
England's position essentially says: "We know you are at higher risk. We simply do not yet possess sufficient certainty to justify looking."
Cancer, unfortunately, has never required certainty before proceeding.
There is another uncomfortable truth here. Every healthcare system rations. Canada does. Britain does. The United States does, although Americans prefer to call it "insurance coverage decisions" because that sounds less alarming. The question is not whether rationing exists. The question is whether we are honest about it.
When a government says, "We cannot justify screening broader groups because evidence remains incomplete," that may be scientifically defensible. When critics hear, "We cannot justify screening broader groups because the costs, complexity, and consequences would be substantial," they may also have a point. Both statements can be true simultaneously.
What makes the policy vulnerable is that it feels less like a confident embrace of modern evidence and more like a holding pattern. A nation that invented radar, penicillin, and the industrial revolution has essentially announced that it would like several more years to think about whether high risk men should receive more screening.
Cancer, displaying its usual lack of respect for committee schedules, is unlikely to wait.
The real scandal is not that England has chosen a narrow screening program. The real scandal would be if the ongoing trials confirm that broader risk based screening saves substantial numbers of lives and policymakers spend another decade debating whether those lives are worth the inconvenience of finding them. That is the danger of becoming so determined to avoid one kind of mistake that you institutionalize another.
Men like me with Gleason 6 are a different animal than you men with advanced prostate cancer.
It's clearer now that PSA can save some lives. But the cost is men like those of us with Gleason 6 and favorable 3+4 can encounter overdiagnosis and overtreatment while men with metastatic prostate cancer are being underdiagnosed and undertreated.
It's a bad bargain for all of us.
Things are changing with MRI, biomarkers and AI. Many are avoiding biopsies and therefore diagnoses and overtreatment.
It is a dilemma.
UK, and maybe other countries, will learn more from TRANSFORM.
Hans so well said, especially, "What makes the policy vulnerable is that it feels less like a confident embrace of modern evidence and more like a holding pattern.", and supports the Imperial College London, "....views of clinicians involved in diagnosing and treating prostate cancer...not routinely captured during the decision-making process." In your words, Hans, coupled with Howard's continued commitment to us, one can no longer claim ignorance of the controversy, for the issue of "bullied acquiescence" written about in the Journal of Clinical Ethics is front and center, RIPE within the profession! To those wo have not shown support for this blog not in the medical field, where else would you learn of research directly bearing on your care?
Not prostrate but related.
https://www.msn.com/en-us/health/medical/how-long-will-we-live-after-turning-70-a-straightforward-test-might-provide-the-answer/ss-AA1XbV3w?ocid=msedgdhp&pc=DCTS&cvid=6a29b8e79f544246a4c014fe2225016c&ei=110#image=1
The strongest possible condemnation should be reserved for things like selling cigarettes in pediatric wards, replacing parachutes with positive thinking, or serving English beer at room temperature and calling it a feature. What England is doing is not madness. It is caution. The real question is whether it is cautious to the point of paralysis.
The devastating critique is not that policymakers are evil, indifferent, or stupid. It is that they remain trapped in a prostate cancer debate that often sounds as though it is still taking place in 1998. Their entire argument rests on a legitimate observation: PSA testing led to overdiagnosis and overtreatment. This is true. Men were diagnosed with cancers that may never have harmed them, and some suffered unnecessary side effects. Nobody disputes this.
The problem is that medicine has not remained frozen in amber while the committee continued studying spreadsheets.
The policy reads like a government document written by people who have become so terrified of treating men unnecessarily that they have become comfortable not finding them at all.
Consider the logic. A 55 year old Black man with a father and brother who had prostate cancer is apparently not high risk enough. A man with a strong family history but no BRCA2 mutation is apparently not high risk enough. But a man who checks a very specific genetic box enters the sacred circle of approved concern. This is precision medicine carried to the point of absurdity.
Imagine applying the same standard elsewhere. "We recognize that your house is on fire, sir. We can see flames emerging from the windows and smoke pouring from the roof. However, our models indicate that only houses with red front doors and Labrador retrievers statistically benefit from immediate firefighting. We are funding a promising study regarding blue doors. Results expected sometime after your living room has collapsed."
The entire exercise reveals a peculiar bureaucratic instinct. When confronted with uncertainty, institutions often conclude that the safest action is inaction. If ten men are harmed by overtreatment, that is measurable and visible. If ten men die because their cancer was never found early enough, that harm is dispersed, delayed, and easier to ignore.
Politically, overtreatment creates victims with names. Undertreatment creates statistics.
The irony is that the very advances designed to solve the old screening problem are largely ignored in the argument. MRI was not part of widespread screening pathways thirty years ago. Active Surveillance was not nearly as accepted. Genetic risk models were primitive. Risk stratification was crude. Yet many of the assumptions driving today's decisions are still built on data from an era when the internet made screeching dial up noises and grown adults believed fax machines represented the future.
Meanwhile, specialists who spend their lives diagnosing prostate cancer increasingly seem to be saying the same thing: perhaps the balance has changed.
When two thirds of practicing urologists disagree with the policy, it may be worth asking whether the people treating the disease know something that the policy model does not.
The most troubling aspect is not the exclusion of average risk men. Reasonable people can debate that. It is the exclusion of groups that almost everyone agrees are at elevated risk. Black men. Men with strong family histories. Men whose risk is obvious without requiring a genetic sequencing report thick enough to stun a badger.
England's position essentially says: "We know you are at higher risk. We simply do not yet possess sufficient certainty to justify looking."
Cancer, unfortunately, has never required certainty before proceeding.
There is another uncomfortable truth here. Every healthcare system rations. Canada does. Britain does. The United States does, although Americans prefer to call it "insurance coverage decisions" because that sounds less alarming. The question is not whether rationing exists. The question is whether we are honest about it.
When a government says, "We cannot justify screening broader groups because evidence remains incomplete," that may be scientifically defensible. When critics hear, "We cannot justify screening broader groups because the costs, complexity, and consequences would be substantial," they may also have a point. Both statements can be true simultaneously.
What makes the policy vulnerable is that it feels less like a confident embrace of modern evidence and more like a holding pattern. A nation that invented radar, penicillin, and the industrial revolution has essentially announced that it would like several more years to think about whether high risk men should receive more screening.
Cancer, displaying its usual lack of respect for committee schedules, is unlikely to wait.
The real scandal is not that England has chosen a narrow screening program. The real scandal would be if the ongoing trials confirm that broader risk based screening saves substantial numbers of lives and policymakers spend another decade debating whether those lives are worth the inconvenience of finding them. That is the danger of becoming so determined to avoid one kind of mistake that you institutionalize another.
Hans, Thanks for the thoughtful reaction.
I am very divided on this.
Men like me with Gleason 6 are a different animal than you men with advanced prostate cancer.
It's clearer now that PSA can save some lives. But the cost is men like those of us with Gleason 6 and favorable 3+4 can encounter overdiagnosis and overtreatment while men with metastatic prostate cancer are being underdiagnosed and undertreated.
It's a bad bargain for all of us.
Things are changing with MRI, biomarkers and AI. Many are avoiding biopsies and therefore diagnoses and overtreatment.
It is a dilemma.
UK, and maybe other countries, will learn more from TRANSFORM.
This remains a public health disaster.
Howard