When high-profile figures publicly discuss their prostate cancer, the public health impact can be immediate. The media coverage raises awareness. More men may seek information or medical advice.
We’ve seen a recent example, with media personality Jeremy Clarkson who last week revealed his prostate cancer diagnosis. This was followed by a spike in men going to Prostate Cancer UK’s website to check if they were at risk.
Other high-profile men to disclose their diagnoses include author and broadcaster Stephen Fry , actor Ben Stiller and former US president Joe Biden .
But such publicity can also have its downsides. It can skew our perception of prostate cancer, and who might actually benefit from testing and treatment.
Raising awareness has a trade-off
Prostate cancer remains a major cause of cancer death among men. And the increased attention that follows a public figure talking about their prostate cancer can help reduce stigma around men’s health and encourage conversations about symptoms.
Such public disclosures can draw attention to aggressive (fast growing) or metastatic (spreading) prostate cancer. Men who have never considered prostate health may be prompted to seek information or discuss their risk with a doctor. This can be particularly helpful for men at higher risk.
But most prostate cancers are not immediately life-threatening. You may have heard that many men “die with prostate cancer, not from it”. This is because some prostate cancers grow so slowly they would never cause symptoms or shorten life.
Yet, media coverage has always tended to exaggerate the benefits of prostate cancer screening and not fully explain the risks and uncertainties. Celebrities are also often viewed as trusted role models. And their personal experiences can shape public understanding of cancer and screening in ways that are not fully aligned with the scientific evidence.
So their stories can create a skewed impression of an individual’s risk from prostate cancer . This may lead to over-screening, detection of extremely-slowly-growing cancers, and provoke rushed decisions for immediate treatment that isn’t always needed.
To screen or not?
The main screening test is the prostate-specific antigen (PSA) blood test. This can detect cancers earlier.
But it can also identify “false positives”, when high levels turn out not to be due to prostate cancer. The test can also identify basically dormant tumours that will never cause harm . Unnecessary investigations or treatments of these tumours can expose men to potential harms including urinary, bowel and sexual side effects.
Prostate cancer screening using the PSA test remains widely debated. And this debate has shifted following updated evidence. This includes from a recent Cochrane review , which draws together the best available evidence.
Earlier versions of these reviews found insufficient evidence PSA screening reduced prostate cancer deaths.
But the new review found PSA-based screening likely reduces deaths from prostate cancer at a population level. However, the number of men who may benefit from screening is small.
It estimated screening 1,000 men would lead to one to two fewer prostate cancer deaths in the long term compared to not screening. This reduction in deaths from screening was only seen after many years of follow-up (11-23 years in the trials included in the review). That’s because so many cancers detected by the PSA test are slow-growing.
Against this benefit, the review found potential harms from the increased number of men diagnosed and treated. Among the 1,000 men, screening would mean 16 extra men would be diagnosed and treated compared to not screening. Some of these men would likely be overdiagnosed and overtreated for cancers that would not cause harm if they’d been left undetected.
Overall, the review did not conclude every man should have a PSA test. It found while screening may reduce the chance of dying from prostate cancer, it can also lead to unnecessary tests and treatment.
The balance of benefit to potential harms can also be easily shifted. That’s if there’s overly frequent testing of men unlikely to benefit (with overdiagnosis and overtreatment), or insufficiently frequent testing of men at high risk (with underdiagnosis and undertreatment).
All this may come with considerable costs to both individuals and the health system.
New advice
The new evidence included in the Cochrane review is leading to updated clinical guidelines in many countries, including Australia and the United Kingdom.
The revised draft Australian guidelines are likely to recommend that men who ask for testing must be informed of the benefits and harms first. The draft guidelines also have targeted recommendations for specific groups.
The UK National Screening Committee recommends only a more targeted offering for men aged 45-61 who have particular genetic variants (BRCA2 gene) with a family history of breast, ovarian, pancreatic or prostate cancer.
Both of these guidelines support a shared decision-making approach. This is where men are encouraged to discuss their age, family history, overall health, personal values, and tolerance for uncertainty with their health-care provider before deciding whether to have a PSA test .
Both guidelines advise against widespread, population-wide screening.
So what next?
Decisions around prostate cancer screening are complex. Men have to weigh up
both the benefits and harms for each step from PSA testing through to potential treatments.
The latest evidence suggests PSA screening can save some lives, but the benefit is modest and comes with important trade-offs.
Celebrity stories should be a starting point for informed conversations. Public awareness is valuable when it leads to informed decision-making, not when it replaces it.
