Invisible men: Older men with prostate cancer.
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A recently published paper contains what the medical authors claim is the first attempt at producing guidelines for hospital specialists on the medical management of older men with prostate cancer.
The difficulty treating older men with prostate cancer is knowing how much you can reasonably expect to extend life when other possible causes of death might intervene and balancing that with interventions that might decrease quality of life without extending survival much, if at all. It was published by the International Society of Geriatric Oncology, in the British Journal of Urology 2010;106, 460-462.
Why my emphasis on first attempt? Well, prostate cancer is the most frequently diagnosed cancer in men in the USA and in Europe and it is predominantly a disease of older men, men in their early 70s and older. Seventy one percent of deaths from prostate cancer occur in men aged 75 and over. So, in 2010, we’ve got a first attempt? In the group most likely to be diagnosed with it and most likely to die from it?
If not even the doctors have been thinking much about the men most likely to get it and die from it, what have we been doing with the much increased profile of prostate cancer in the last few years?
We’ve been exercising our society’s ageist prejudices with the increased profile of the cancer, that’s what. Just as we have with breast cancer.
We’ve used the profile of prostate cancer to create a lot of younger men with it. The incidence in the UK has almost doubled in the last decade. Death rates and ages are broadly static but the average age at diagnosis has crept down, to early 70s in this country. It won’t be long before it’s late 60s as it is in the USA.
This isn’t because of some epidemic caused by hormones in the water or proximity to pylons. It’s increased awareness and interest in the PSA test which yanks more prostate cancer into the open. Mostly, it isn’t the prostate cancers that kill that are diagnosed, even if the men having a PSA test believe it did save their life. It’s possible, sure. But stats suggest that it's not likely - it takes 48 men to be diagnosed and treated after a PSA test, for 1 man’s life to be saved. But all 49 will be grateful.
No one with a heart will enquire into some man’s evidence when he says the PSA test saved his life. The inclination to respect a personal anecdote is strong, it has a lot of face value, especially if the face is one you know, respect or is similar to yours. The listener may nod and go and ask his GP for a PSA test. Or just pay up at his local private health clinic, if the NHS GP’s first sentence begins with ‘Ah yes, the PSA test… it’s not that straight forward…’
But do engage brain go and find out more.
The end result is as we are today - more and more prostate cancer cases and few inroads into the numbers of men who die. The older men. If you search anywhere on Google you’ll find PSA evangelists and conspiracy theorists. You'll also find more nuanced accounts dealing with the ambiguities, showing why the PSA test is a liar, how it can be not fit for purpose on the one hand, whilst also being the best we have, on the other. Look for Richard J Ablin. He discovered PSA and regrets it.
Who said life was straight forward?
If we’d spent all the dollars and pounds, column inches, advocacy and PR finding a test that worked instead of crowbar-ing the PSA test into a role for which it was never intended we might be doing a bit better on the ‘saving lives’ front. But never mind.
There’s a much bigger problem looming - the exponential ageing of the population in developed countries which means the burden due to prostate cancer will increase hugely over the next few years. An effective screening test that saves lives with manageable risks (there’s never no risk) will arrive much more slowly than the cohort of ageing men, coming across the horizon due to increasing life expectancy and medical progress but marching into the gathering storm of increasing prostate cancer risk.
We’re utterly blind to this. The PSA test is an issue for younger men. It’s older men, mostly, who carry the burden of dying of prostate cancer. And there's a helluva lot more of them and more on the way.
In your mind’s eye conjure up a man with prostate cancer. How does he look? Is he 60 or so? Behind each man who dies of prostate cancer under the age of 60 there are another 35 men who die of prostate cancer over the age of 60.
So your mind’s eye may need re-adjusting, to 65 ish? For each man under the age of 65 who die of prostate cancer there are 15 men who die of prostate cancer over the age of 65. Even if we go up to 70?....... Behind each man who dies of prostate cancer under the age of 70 there will still be another 6 men who die of it over the age of 70.
Younger men with prostate cancer carry a different burden from older men but we seem intent on prioritising the younger man’s. Both are equally important but they are quite different.
When are older men going to get any profile in campaigning, on access to health services and the clinical research, information and support they need? Or the understanding that their health can be a lot more complicated. They will be at risk of 'what do you expect at your age?' - uttered, or internal, it doesn't matter.
As more men achieve greater age with matching greater risk of getting prostate cancer when frailer, more vulnerable, more likely to suffer are we still going to be listening to the firmer vigourous voices of younger men in their fifties?
Ageing men with prostate cancer - they are already a game changer. The elephant has definitely entered the room. But no one's looking.
