CARDIOVASCULAR RISK FACTORS AND DIABETES

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3. Phillips P, Wilson D, Wakefield M, Beilby J. Death and dia- betes. Med JAust 1990; 153: 173.

4. Gross PF, Tiffin A. Total economic costs of i a b e k s in Australia. Sydney: Institute of Health Economics, 1991.

5. Diabcies in Australia. Canberra: Australian Diabetes Society. Canberra, 1988.

6. Nutbeam D, Thomas M, Wise M. National action p h n - d i a - betes lo the year 2000 and bqiond. Canberra: Australian Diabetes Society, 1993.

7. Wilson D, Wakefield MA, Taylor A. The South Australian Health Omnibus Survey. Health h t JAust 1992; 2: 47-9.

8. National Heart Foundation. Risk Factor Reuafencr Study. Survq no. 3, 1989. Canberra: Australian Institute of Health, 1990.

9. Australian Bureau of Statistics. Australian standard classijica- tion ofoccupations. Cat. no. 1222.0. Canberra: AB!3, 1990.

10. Kelly JL, Evans MDR. Using ASCO for socioeconomic analysis: assessment and conversion into status and prestige indicts. Canberra: Research School of Social Sciences, Australian National University, 1988.

11. Carter Center of Emory University. Closing the gap: the problem of diabetes mellitus in the United States. Diabetes C a n 1985; 8 391-405.

12. Masson EA, MacFarlane IA, Priestley CJ, Wallyrnahmed ME, Flavell HJ. Failure to prevent nicotine addiction in young neonle with rliah-tps. Arch Dis Child 1992: 6 7 100-2.

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Stacy RD, Lloyd B. The investigation of beliefs about smok- ing among diabetes patients: information for improving ces- sation efforts. Patient Educ Couns 1990; 15: 181-9. Reid DJ, Killoran AJ, McNeill AD, Chambers JS. Choosing the most effective health promotion options for reducing a nation’s smoking prevalence. Tobacco Control 1992; 1: 185-96. Kingwell BA. Jennings GL. Effects of walking and other exercise programmes upon blood pressure in normal sub- jects. MedJAust 1993; 158: 234-8. Dickinson JA, Wiggers J, Leeder SR, Sanson-Fisher RW. General practitioners’ detection of patients’ smoking status. MedJAust 1989; 150 420-6. Roche AM. When to intervene for male and female patients’ alcohol consumption: what general practitioners say. Med J

Reid ALA, Webb GR, Hennrikus D, Fahey PP, Sanson-Fisher RW. Detection of patients with high alcohol intake by gen- eral practitioners. BkfJ 1986; 293: 735-7. Cockburn J. Killer D, Campbell E, Sanson-Fisher R. Measuring general practitioners’ attitudes towards medical care. Fam Ract 1987; 4 192-9. Reed BD, Jensen JD, Gorenflo DW. Physicians and exercise promotion. Am J R e u Med 1991; 7: 430-15. Wallace PG, Brennan PJ, Haines Ap. Are general practition- ers doing enough to promote healthy lifestyle? Findings of the Medical Research Council’s general practice research framework study on lifestyle and health. BMJ 1987; 294 94042. Clynn ‘IJ, Manley M W , CullenJW, Mayer WJ. Cancer pre- vention through physician intervention. Sm’n OncoZl990; 7: 391-401.

A m t 1990; 152: 622-5.

POINT OF VIEW

Prostate cancer screening and men’s health In 1990 I attended a Cancer Council briefing on major cancers. After spending some time on breast, cervical and skin cancer we came to the page in the flip chart headed ‘Prostate Cancer’. The presenter glanced at the heading, then, as he flipped over the page, he joked ‘Well we all know about men and fin- gers, don’t we?’ Everybody laughed and we went on to the next topic.

Today, such cavalier treatment is unlikely. Prostate cancer has become part of the general health debate carried on in the community and through the media. Reports of the recent controversy over breast cancer funding, for example, highlighted two areas for comparison, acquired immunodeficiency syndrome (AIDS) and the ‘male’ diseases, prostate and testicular cancer. While the AIDS lobby was cited as a precedent in politicising the health research process, prostate and testicular cancer were offered as the logical comparison for evaluating pri- orities and funding. This tweway contest between breast and the ‘male’ cancers was not simply media inventiveness. The then Minister for Health, Senator Richardson, in responding to criticism over breast cancer funding, said it was tragic that 2600 women died annually of breast cancer, but 2300 men died each year of testicular and prostate can- cer. He also said that breast cancer research received $1.5 million annually, or 10 per cent of the cancer budget, and the male diseases received about $300 000, but the media did not focus on the male disorders because they were not ‘fashionable’.’

In lobbying terms, prostate cancer is poised to become fashionable. The statistics on death and risk are easily conveyed and the differences in research funding for breast cancer and prostate cancer appear stark. On the other hand, the reasons for lack of screening are not easily sloganised. A recent Lancet article pointed out that, compared to breast cancer, we know little about the natural history of prostate cancer, the adequacy of the screening tests and the efficacy of early treatment. The author con- cluded that even to commence a trial of prostate cancer screening would be unethical at this stage, and called for open discussion of the issues.* Letters to the Lancet in response contested the measure- ment of survival rates, the evidence of testing efficacy, the ability of clinicians to identify poten- tially harmless cancers, and the statistical models used in previous studies.=

The complexity of the arguments and the lack of consensus surrounding prostate cancer screening preclude a straightforward response to suggestions for aggressive strategies for detection. At the same time, a number of recent developments in Australia make the climate for championing prostate cancer particularly auspicious.

The perception that men in Australian society are in crisis seems to be common among media workers. This means that health issues framed as ‘male issues’ are likely to receive considerable coverage. But the popular media are not the only ones to have discov- ered ‘male’ health needs recently. In 1993, the Australian FamiZy Physician, the journal of the Royal Australian College of General Practitioners, issued its second special edition on ‘Men’s health’. Its edi-

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torial noted that whereas ‘specific problems of the prostate, the genitals and male sexual functioning were important’, asking ‘what it is it that drives men to behave in an unhealthy fashion?’ is also ~ritical.~ Nurses and other health workers are currently run- ning programs specifically aimed at men in the areas of domestic violence, cancer awareness, stress man- agement and general health knowledge. Organi- sations with high male memberships such as Rotary and Apex have also become direct providers of awareness programs in colorectal, prostate and tes ticular cancer. Gutbusten, a weight reduction pro- gram designed specifically around men’s needs, has been successful in a number of areas and is to be offered as a franchise around Australia.

The increasing reliance on epidemiological evi- dence for setting targets and measuring success has also drawn attention to male health outcomes. Health regions, such as the Pilbara in Western Australia, the Peninsula and Torres Strait Region in Queensland and Southwest Sydney in New South Wales include males as a target group on regional plans. This, in turn, has led to conferences, work- shops and publications to increase awareness of male health needs among regional health staff? The new health minister, Carmen Lawrence, stated that men’s health needed attention, reflecting a similar process at a national level. While the 1988 Health for aU report simply noted males’ poor health status, the 1993 national Guuk and hrgets report broke new ground by listing males as priority targets in a num- ber of categories from skin cancer to interpersonal violence.

In addition to these general factors, a well- resourced Prostate Disease Awareness Committee has been set up with a grant from Merck Sharp & Dohme (Australia) . The American parent company, which sponsors similar groups in other countries, manufactures Proscar (finasteride) a prostate- shrinking drug used in the treatment of benign p r e static hyperplasia. The committee, which is man- aged by Edelman Medical Communications, includes representatives from the Australian Kidney Foundation, the Combined Pensioners and Superannuants’ Association and the Returned Services League of New South Wales. It has broad educational aims and is preparing a videu-based pre- sentation on prostate disease to be shown by health workers to men across Australia.

What happens if prostatic diseases do become ‘fashionable’? One consequence, if the breast can- cer foundation established in the May budget is a precedent, will be separate funding for prostate can- cer research. This is likely to be opposed by medical researchers as replacing scientific merit with lobby- ing. However, the research funding debate may be overshadowed by the problems caused by an increase in the general awareness of prostate dis ease. Even though benign prostatic hyperplasia is far more common than prostate cancer, the symptoms are identical. Awareness of prostate disease will cre- ate pressure for a test which will allow the early diag- nosis of prostate cancer.

The use of screening tests for detecting cancer has been a major point of debate in the medical lit- erature. As well as discussion of individual tests,

there has been tension between mass screening of an asymptomatic population and case detection in asymptomatic patients seeking a health check. In the former, clear guidelines have been established to justify the expenditure of public money and to ensure that potential benefits outweigh the risks. In the clinical setting with individual patients, however, general practitioners or specialists may well operate on the basis that the earlier a cancer is found the better. Recognising this dilemma, The Medical Journal of Australia published Australian Cancer Society guidelines for cancer-related health checks as a special supplement to the September 1985 edi- tion? At that time, no methods of early detection for prostate cancer were recommended, owing to lack of evidence. The new guidelines in preparation are unlikely to recommend mass screening for prostate cancer but may follow the American Cancer Society guidelines in recommending that annual digital rec- tal examinations (DREJ be offered to men over 40 years of age requesting a health check.l0

Other tests are available for detecting prostate cancer. Two of the most common are prostate spe- cific antigen (PSA) and transrectal ultrasound (TRUS) . But neither they, nor DRE, are particularly accurate. The DRE, for example, has a positive pre- dictive value (the probability of disease in somebody with a positive test result) of only 0.17 to 31 per- cent” This means that a high proportion of men thought initially to have cancer will, after further investigation, be found to be cancer-free. Since a positive result at screening will require further inves- tigation, and because it is difficult to predict which prostatic cancers will progress, finding the cancer may not benefit the patient. A decision analysis of treatment of men with asymptomatic prostatic nod- ules in general practice found that the men would be worse off if the prostatic nodule found on screen- ing were evaluated and treated.’* However DRE, which is cheap and relatively noninvasive, may be the least likely candidate for inappropriate use, since social attitudes may inhibit widespread rectal examinations. The taking of a PSA blood test and the TRUS are likely to be more acceptable. Sladden and Dickinson have estimated that screening costs using these tests for the 1.5 million Australian men over 50 could be as high as $300 million per year,ls a figure, it should be noted, which is 20 times the total existing cancer research budget.

Unfortunately, the potential conflict between a newly alerted public, wanting to know if they have cancer, and a properly cautious scientific commun- ity, will not be solved through researching the effec- tiveness of the tests. The scientific gold standard required in such cases is provided by randomised controlled trials. Such trials are under way, but of necessity, require many years to complete. The European trials, testing different combinations of screening, will not be complete until the year 2000.

In the past, health authorities have been able to contain the use of screening tests by issuing guide- lines to general practitioners and refusing to spon- sor government-funded mass screening. But the context of public health debate has changed. As noted above, our health culture is now one where men’s health is highly visible and where articulate

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groups are promoting prostate awareness to a recep tive public, We can see a possible future in develop ments in the United States. There, the proportion of patients with newly diagnosed prostate cancer who had the PSA test rose from 5.8 per cent in 1984 to 68.4 percent in 1990." Increasingly, however, the combination of political, consumer and commer- cial pressures is sidestepping the scientific commu- nity to encourage testing with DRE and PSA in men without symptoms. In the United States, Senate minority leader Bob Dole sponsors a touring Bob Dole Prostate Cancer Detection Unit, staffed by vol- unteer urologists and physicians, which screens up to 2000 men at each site.15 Free screening is also pro- vided at other sites across the United States during Prostate Awareness Week (estimated at 600 OOO in 1993). The December 1992 issue of the Saturday Evening Post contained a tear-out Christmas pre- sent-a gift certificate for a PSA test from the doctor of your choice.

For those hoping that Australian health policy would never be prey to such folly, the recent devel- opments in cancer funding must provide food for thought. The Commonwealth decision to establish a breast cancer foundation, bypassing the established National Health and Medical Research Council review process, was made in the face of opposition from the Australian Medical Association, the Royal Australian College of Physicians, the Australian Cancer Society and prominent researchers and clin- icians, including those working in the breast cancer area. The announcement of the funding was made at the same time that a national Breast Cancer Week was announced.

Breast cancer may also provide a positive model. The revised health promotion guidelines for breast cancer suggest that skilled counsellors be provided to women to assist with the unravelling of a complex health decision process. This concept could be bor- rowed for men concerned with prostate disease. Where the breast cancer advice was to be offered in relation to treatment (and the treatment decisions for men are not exactly simple either) the notion could be extended to cover all aspects of screening. On a larger scale, the provision of spokespersons for men's health interests has not, to date, been seen as necessary. After all, most urologists are male. But without suggesting any inadequacy on the part of urologists. the idea that male medical specialists could speak on behalf of all Australian men flies in the face of current understanding of consumer rights. There are groups available. Apex and Rotary

have been providing health education outside Cancer Council guidelines. They could be invited to join a cooperative educational approach to men. Male organisations (such as those represented on the prostate awareness committee) with little expe- rience in health advocacy, could be resourced and skilled to represent men in health debates.

Given the society-wide awareness of general men's health and the increasing awareness of prostate can- cer in particular, the health research community has a choice. We can continue to use epidemiological arguments to decry ill-informed yearning for screening tests or we can try to build on the height- ened interest in male health issues to develop, in Australian men and boys, an informed awareness of health care issues and options.

Richard Fletcher Discipline of Paediutncs, Uniuersily of Newcastle

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11. Chodak CW, Schoenberg HW. Progress and problems in screening for carcinoma of the prostate. Wmld J Surg 1989; 13: 60-4.

12. M o l d y , Holtgrave DR, Bisman RS, Marley DS, et al. The evaluation and treatment of men with asymptomatic prostate nodules in primary care: a decision analysis. JFam Aact 1992; 94.561-8.

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