Reviewed by Peter Sainsbury
Population Health, Clinical Service Cluster (Western), NSW Health
In Let sleeping dogs lie? Chapman, Barratt and Stockler have two main purposes. First, to present in a readily understandable form all the facts men who are considering having a prostate cancer screening test should have access to: “We wrote this book to provide men with information that is rarely included in ‘pre-screening’ public information about prostate cancer” (page 115). That men should be able to make “a truly informed choice about whether to get tested for prostate cancer” (page 89) is the authors’ desire. Second, to argue that a prostate cancer screening program is not justified if all the evidence is considered. They also have a secondary, quite explicit, purpose: to suggest that individuals and organisations who are promoting prostate cancer screening are misleading men, particularly young men, by being selective in the information they present and that they have vested interests that they are trying to advance.
When reviewing a book where the focus is on information availability, transparency and decision making, it is prudent for me to make some relevant personal declarations. First, I will be 60 next birthday and I seldom enjoy an uninterrupted night's sleep. Second, I know all three authors well. Third, you've heard about climate sceptics, well, I'm a cancer screening sceptic.
Let me start by summarising the information presented in Let sleeping dogs lie? that the authors want to be more widely available. Prostate cancer is rare before the age of 50 but gets increasingly common after that, affecting 40–50% of men in their 70s. The detected incidence of prostate cancer in Australia increased from 81 to 170 per 100,000 between 1976 and 2006 but the age-adjusted death rate from prostate cancer has remained relatively stable, 36 per 100,000 in 1968 and 31 per 100,000 in 2007. Prostate cancer accounts for 4.2% of all male deaths in Australia (about 2,900 per year). More than 80% of men who die from prostate cancer are aged 70 or more. About 10 men per year die from prostate cancer before age 50 in Australia. Most prostate cancers cause no problems and remain undetected, and the vast majority of men with prostate cancer die with it rather than from it. Prostate Specific Antigen (PSA) screening cannot differentiate benign from malignant prostatic disease or slow growing malignancies from the small minority that will kill. The two best randomised controlled trials of screening indicate (in my crude summary) that if 1,000 50–70 year old men have a PSA test approximately 200 will test positive, approximately 50 will have cancer confirmed by biopsy and undergo treatment, and approximately 1–4 deaths (of the 4–9 that would have occurred without screening) will be avoided over the next 9–14 years. Thus, 46–49 of the 50 men with biopsy-confirmed prostate cancer will have had unnecessary biopsy and treatment, will live thereafter with the knowledge of having had cancer and will probably wrongly conclude that screening and treatment saved their life; many of these men will have unnecessary persistent impotence, urinary incontinence and bowel problems. Worldwide, no government, peak cancer control agency or independent review has supported prostate cancer screening. The authors conclude that “the best available evidence shows a modest benefit of screening which must be weighed against the substantial risk of harm through overdiagnosis and overtreatment” (page 110).
The authors, who have extremely complementary expertises for writing this book, have succeeded in penning a concise, clear, informative, engaging text. I am confident that anyone who isn't already an expert who reads the book will be better able to make a decision about having a prostate screening test (or help someone make that decision). They will also be more able, should they wish, to contribute to the public debate about prostate screening programs.
The problem, though, is that although the book has been written for Joe Average (with frequent personalising references to ‘you’ and no mention of broader concerns such as cost-effectiveness), I can't see many ordinary blokes faced with a decision about a PSA test reading this book. Yes, I found it easy to read but I'm a health professional who is already well versed in the concepts and the language. It's difficult to believe that a farmhand in Cowra or a bus driver in Collingwood is going to absorb its contents quite so readily. For comparison, think superannuation! Consequently, I rather suspect that the main audiences for Let sleeping dogs lie? will be medical students and GPs, for whom the book is a very nice primer on the prostate and prostate cancer (including its risk factors and management), and male health professionals unsure about whether to have a PSA test. Perhaps the brotherhood at large would benefit more from the main messages being presented in traditional print and media formats and via 21st century electronic networking sites, apps, games, etc.