Equality of the sexes is needed in screening

MEDICAL MATTERS:MEN ARE neglected when it comes to cancer detection. It's a strong statement, I know, and there may be lots of reasons why this is the case, but an extraterrestrial visitor couldn't but notice how much more we prioritise women's cancers in the Republic relative to those in men.

Now before anyone misconstrues my statement, I am not advocating that women’s cancer care receive less funding. Far from it. If anything, men need to learn that the prioritisation of women’s cancer came about after many years of hard lobbying by women.

Take the National Cancer Screening Service (NCSS). It has a budget of €58 million this year and has two principal arms at present: CervicalCheck and BreastCheck. Both national screening programmes are aimed at women’s cancers. It is due to roll out a bowel cancer screening programme which will obviously benefit both men and women. But, as of this moment, it doesn’t offer any programme specifically for men.

This is not because of any anti-male bias on behalf of the NCSS. It mainly reflects a lack of evidence to justify population-based screening for cancers such as cancer of the prostate. The Swedish authors of the most recent research into prostate cancer screening have said it may give rise to both overdetection and overtreatment.

In a well-designed trial published in the British Medical Journalthis year involving more than 9,000 men who were followed up over a 20-year period, researchers found that screening for prostate cancer using a combination of a rectal examination and a PSA blood test did not prolong the survival of those men who developed the disease.

This is because the tumours found in the men who were screened were smaller and more localised within the gland than those diagnosed opportunistically, suggesting that screening is detecting cancers that are low risk because of their slow rate of growth. If left alone, many of these would cause no harm.

To initiate a viable screening programme for a male cancer, you need an accurate and reproducible test that can pick up cancer at an early point in its development. For testicular cancer, there is no test, although there may be some merit in encouraging men in their 20s to periodically self-examine for lumps.

What about cancers that affect both sexes but are more prevalent in men? Lung cancer is a big male killer because of late diagnosis; there is some promising work suggesting smokers could be screened using CT scans but probably not yet enough evidence to justify a formal programme. Other cancers with a slight male predominance are cancers of the mouth, the oesophagus (gullet) and the stomach.

But there is definitely an argument for developing some targeted screening for cancer among men. For example, if a man’s PSA (blood test) is 2.0 or higher at age 60, then his risk of developing prostate cancer within the next 25 years is elevated. About one in four men will have a score of 2.0 or higher and, while most of them will not develop prostate cancer, the risk is such that they will benefit from regular screening.

And while male breast cancer represents only 1 per cent of all breast cancers, it does occur with a greater frequency in men with a family history of breast cancer or those who have been exposed to chest radiation in the past. The average age for men to develop breast cancer is 65.

Would BreastCheck consider the following? Create a niche sub programme for men aged 55-70 who have a family history of breast cancer. Target particular men in families known to carry the BRCA2 gene; male carriers of BRCA2 have a cumulative risk for breast cancer of 7 per cent by age 80. It could also include men with a history of therapeutic irradiation.

So, at the risk of annoying the screening purists, can the NCSS seriously look at targeted screening for male breast cancer and prostate cancer? As well as saving some lives, such a move would go some way to rebalancing a cancer screening and awareness scale that currently tips acutely towards those with two X chromosomes.