Determining the burden of prostate cancer is a very difficult task. For the patient and his family, quality and quantity of life are paramount. To the Minister of Health, distributing optimal care to the population within the constraints of a fixed or shrinking budget is the goal. For healthcare providers, trying to balance between two sometimes opposing goals — advocating for the patient to give the best possible individual care irrespective of cost, yet respecting the constraints of a limited health budget — creates a palpable tension.
Recently, two studies have assessed the value of screening for prostate cancer in large populations. The general conclusion of the bigger study was that screening and subsequent treatment may reduce the death rate from prostate cancer by 20%. However, this result was only gained by screening vast numbers of men to find one with cancer, and many men needed to be treated (and incur side effects) to save a single life. The authors note the positive effect on decreased mortality but caution that screening risks “overdiagnosis.”
I find it impossible to minimize the value of saving even a single life, but feel equally that we must minimize the side effects and costs of poor or unnecessary treatment. Two articles in this issue of Our Voice deal with this dilemma. In the feature article, Dr. Yves Fradet, a distinguished urologic oncologist of global repute and a pioneer in the development of tumour markers, presents a thoughtful overview of the prostate cancer conundrum, summarizing the numerous issues related to rising clinical and financial costs associated with this disease. The obvious improvements in terms of treatment side effects and cancer control are offset by risks of overtreatment and ballooning societal costs.
Next, Pamela Hodgson discusses the causes of lymphedema, and strategies to manage this debilitating side effect. Lymphedema is a collection of fluid leading to limb and genital swelling. It is a common side effect of lymphadenectomy (removal of one or more groups of lymph nodes), which is an important diagnostic and therapeutic addition to radical prostatectomy in high-risk patients. It may also follow diminished lymph drainage of the limbs due to cancerous or treatment-associated obstruction.
A strategy for the future will need to define those men who are at true risk of harm from prostate cancer by assessing both genetic and environmental factors. Nutritional or pharmacologic prevention strategies need to be assessed to see if they offer cost-effective ways of mitigating this increased risk. Screening only higher-risk men might offer secondary prevention benefits while sparing the general population the side effects of unnecessary treatment. While these strategies seem intuitively beneficial, Dr. Fradet cautions that more studies will be needed to confirm them and to justify the deployment of our increasingly scarce healthcare resources in order to decrease the high toll of cancer.
We hope you find these and other topics covered in this issue interesting and of value.
