Academic journal article The Hastings Center Report

A Slippery Preventive Slope

Academic journal article The Hastings Center Report

A Slippery Preventive Slope

Article excerpt

Intended as they are for large populations, preventive health measures must meet particularly high safety standards. The best such measures pose no risk at all. A few years ago it was estimated that so modest a measure as a reduction of salt intake could prevent a quarter of the strokes and perhaps a fifth of the heart attacks in the United Kingdom--doing no harm in the process. The drug proposed for the prevention of prostate cancer runs afoul of this standard.

The problem traces back to the landmark Prostate Cancer Prevention Trial, designed to determine whether finasteride, originally used to treat benign prostatic hyperplasia, could cut the incidence of prostate cancer. In the event, it did just that--by 25 percent. Incidentally, however, the PCPT demonstrated that the rigorous search for prostate cancer uncovers all too much of it. The rate of detected disease ran so high in the trial's intensively screened population--originally classified as low-risk--that even the suppressing effect of finasteride was not quite enough to bring it down to the lifetime risk of the general population: 17 percent. The study subjects underwent regular PSA (prostate-specific antigen) testing, a procedure that can detect even asymptomatic cancers and, therefore, results in overdiagnosis and overtreatment.

When PSA screening got going twenty years ago, no one could have foreseen or intended the ensuing epidemic of prostate cancer. With PSA we waded into a quagmire. No wonder some look to finasteride as the way out. The architect of the PCPT has been quoted as saying that, while no one knows whether finasteride reduces mortality, it "does reduce the frequency of prostate cancer treatment and the adverse effects the treatments carry." In the words of another proponent of finasteride, "It is a bit of a strange prevention argument.... We can't say we've avoided cancers that otherwise would have killed people. But we can say we've avoided cancers that people consider significant enough to treat." (1)

Though it may soften the effects of the PSA revolution, finasteride is not risk-free. A third striking finding in the PCPT was that the rate of high-grade or aggressive cancer ran significantly higher in the finasteride group. …

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