Ecancer television now welcomes Otis Brawley. Professor Brawley, you are in a very important position as the Executive Vice-President of the American Cancer Society and you’re talking here in Lyon about prostate cancer screening. A quick question: does it save lives?

We simply don’t know at this point. There are clinical studies that suggest that it does, those studies have some problems; there are clinical studies that suggest that it does not. We simply do not know if prostate cancer screening saves lives, it’s a legitimate scientific question.

Everybody wants to know, or seems to want to know in many countries, if they’ve got prostate cancer, people are very worried about it. What would you say to patients, then, at the moment, and their doctors?

Everybody needs to realise it is a legitimate question as to whether screening saves lives. It is true right now that the harms of screening are actually better proven than the benefits but there may be some benefits. I personally think men need to realise that there are harms associated with screening, there are possible benefits, they need to weigh this and make their own decision as to whether or not they should be screened.

Now, if you could take me through some of this because patients will say, maybe, ‘Can I have a PSA?’ They’ll ask their doctor, ‘Can you test for prostate specific antigen?’ or even the digital rectal examination. Are these recommendable, they don’t seem very harmful to me?

Well, the tests themselves are not harmful, the end results are. We actually have in the United States a higher suicide rate amongst men who end up getting screened and start worrying about their PSA. Actually one of the harms that we do know occurs is a substantial number of men who are cured of prostate cancer actually had a disease that if left alone never would have bothered them. They end up with impotence, they end up with incontinence, they undergo procedures that have up to a 1% chance of death from the cure yet they didn’t need to be cured. So we have that harm. We have men who have elevated PSAs and diagnosis of prostate cancer in the United States who have been locked in their jobs because of health insurance issues, some men have even lost their jobs as airplane pilots and other things, yet they have a disease which never would have bothered them. So there are a number of harms associated with not the screening test itself but the reaction to the screening test result.

Now, you’re an epidemiologist, that’s one of the many things you do, so what’s the natural history of prostate cancer? Can you be reassuring about this for those men who decide not to get screened?

One of the great concerns is so many men have prostate cancer that does not need to be cured that we wonder how many men who by screening and treating we actually cure who need to be cured. In other words, 50-60% of men who have localised prostate cancer if it’s left alone and watched it will never progress and bother them. But if we do a radical prostatectomy on that individual or irradiate them they think they are cured and they are cured but did they need to be cured? We don’t know.

So what proportion would have run into trouble overall?

Our data on outcomes indicate that about 30-40% of men who are found they have localised disease ultimately relapse and have problems from that disease after treatment.

But maybe not death?

Well perhaps not death. About 50-60% of men who we actually treat we actually now believe don’t need to be treated. Unfortunately we don’t have a good test to say, ‘Mr Jones, you have disease that needs to be treated; Mr Smith, you have disease that needs to be watched.’

In fact, though, word on the street is that if you detect aggressive disease it should be treated. Are you saying that might not be true?

Now, I routinely recommend that.

Can you recognise aggressive disease?

You can have disease that looks aggressive under the microscope and I routinely recommend that those men get treated. However, I don’t tell them that they definitely have to get treated, I tell them I think it’s a good idea to be treated as opposed to I know it’s a good idea to be treated.

And what sort of treatment you get depends on which sort of doctor you go to see, doesn’t it?

That’s so true. Urologists tend to want to do surgery, radiation oncologists tend to want to do radiation. I recommend that men have a good conversation with at least one urologist, at least one radiation oncologist, perhaps a medical oncologist who does not have a vested interest, and come to a decision about treatment.

George Bernard Shaw would have said that’s because none of the doctors really have the answer.

That’s exactly true. I actually frequently say we need to realise what it is we scientifically know, what it is we scientifically don’t know and what it is we believe and label them accordingly. In this business of prostate cancer, and unfortunately for some people it is a business, we have a large number of people who have confused what they believe as something that they know. At this juncture we do not know if screening and aggressive treatment saves lives, many of us believe that it does but the patient needs to realise there’s a different between what we scientifically know and what we believe. Some will choose to be screened, some will choose not to be screened. Interestingly, of prostate cancer experts in screening I know very few who choose themselves to be screened. You see, there’s a study in the United States that says 85% of urologists over the age of 50 choose to be screened but among internal medicine doctors about half choose to be screened. So even amongst the doctors who understand this problem we don’t know what to do.

But what you are saying, though, is that patients need information although the information is confusing, isn’t it?

I think patients need to realise how confusing the information is and they need to realise that they need to make an educated guess as opposed to their physician making that guess for them.

You’re the American Cancer Society, what are your recommendations then?

It’s very interesting, many people don’t realise this. The American Cancer Society, other organisations, be it the American Urological Association or the European Urology Association, the National Comprehensive Cancer Centers Network, all of them have published statements that say men need to know the potential risks and realise that there are potential risks. They need to realise that there are some potential benefits and the individual man needs to make a decision. Literally no professional organisation today says all men should be screened; they say men need to make a decision after understanding this problem.

And quite understandably doctors want to help if a patient is anxious.

I think that is true.

But you could say quite firmly that watchful waiting, both from the patient and from the doctor, might be the right policy?

Once diagnosed watchful waiting is the right policy for the majority of patients. The problem is we don’t have good tests to really nail that down and say, ‘This patient definitely needs to be watched; this patient definitely needs to be treated.’ Again, I will re-emphasise, there are so many patients who don’t need to be cured, we don’t know how good our treatments currently are.

And that’s your last word then? Or what is your last word here from the meeting in Lyon, this international meeting of national cancer institute directors?

My last word is that patients and doctors need to realise that this is an open question. There are a few doctors out there who just say screen, screen, screen, and just do not understand that this is a legitimate open question. When you really get to the experts, the experts say, ‘We don’t know the answer, let’s tell patients the truth. We don’t know the answer.’  A guess or an estimate has to be made. Perhaps the patient and the doctor together, after discussion, should make that guess or perhaps the patient should make the guess.

Otis, thank you very much for joining us on ecancer television.

My pleasure.