Listener 20 February, 1993.
Keywords: Health Economics
The recent outburst over the relative importance between prostate cancer and cervical cancer has numerous aspects to it, some of which illustrate economic principles. Most people will be aware that women are prone to cancer of the cervix, and that regular examination can identify pre-cancerous conditions which usually can be simply treated to prevent cancer. The prostate gland in men’s lower abdomen – the location is presumably the reason the parallel is drawn – is also prone to cancer. Prostate examination can identify a cancerous condition but, and this is what is crucial for the economic analysis, treatment at this stage is not nearly as effective as treatment made after a positive cervical smear test.
Much was made, in the more hysterical outbursts, about the fact that about four times as many men die of prostate cancer as women die from cervical cancer. But that tells us little. You do not deploy resources, according to how big a problem is: deployment should be based on how effective the resources are at tackling the problem. The difference in mortality between the two conditions may simply indicate that prevention of cervical cancer is more effective than, treatment of prostate cancer.
That we do not have a totally effective treatment of prostate cancer is not even a reason for a massive increase in research on it, or for seeking a test identifying the precancerous condition. Male prostates are much the same throughout the world, so any increase in our efforts would be minuscule in terms of the world effort.
This leads me to medical research strategy. The previous remark might suggest that New Zealand should do no medical research, but bludge off the rest of the world, or confine itself to issues specific to New Zealand – such as where our environment or social behaviour differs, or how the Maori gene pool sometimes appears to leave them more prone to some conditions. However, local research is not for output purposes only. It assists the transfer of findings from overseas By having top-level medical research units in New Zealand we ensure that we have the best (and early) access to research done elsewhere, allowing us to apply it effectively here.
I have very strong views on this matter, because that is what went wrong with economic advice in the 1980s. The Treasury has no research capacity, and naively adopted overseas analysis without any of the moderation and maturity of understanding which research experience gives. This was a major cause of the economic devastation of recent years, but I won’t go on.
Where the public discussion on prostate cancer has been misled is about the failure to distinguish between productive and prudent strategies.
By productive I mean that there is strong evidence that the strategy works, and the resources used are effective, We know that stopping tobacco smoking reduces susceptibility to certain sorts of cancer. Over the years an impressive set of research studies, on different populations, using different methods, collectively confirms this judgement. Potentially then, anti-smoking campaigns prevent cancer. although the resources need to be spent effectively (which explains the recent shift to campaigns targeted at vulnerable groups). Reducing smoking (better still, giving it up altogether) is a productive medical strategy.
On the other hand we don’t have a set of comprehensive studies of the impact of the sun on melanomas (skin cancers). There is research evidence which is suggestive white Australasians, who live in a sunnier clime than their European cousins, suffer more – but the total evidence is not overwhelming in the way that smoking evidence is. However, the personal cost of being careful about sunburn is not great, so it is sensible to be prudent. It is probably also prudent for the country to campaign a little to ensure that everyone knows this, but it it not nearly as urgent a priority as stopping smoking (and preventing the young from starting).
Similarly, there is no great objection to a campaign to increase awareness of prostate cancer, although it is less clear what then happens. The information does not assist prevention, although the earlier the detection, the more likely that any treatment will be successful.
You may think it unfair that we put all the emphasis and public spending on cervical cancer. That may be pretty tough for us men, but mother nature does not always treat people equally: the good news is that not a single man has died from cervical cancer. If a decision was made to spend more equally on men and women’s preventative health (it would be a political decision, for there is no economic logic for or against it) we should not look for the closest male parallel to cervical cancer. After considering all the possibilities, I should not be surprised if we alighted on heart conditions, which kill many more men (and some women) than does prostate cancer. Some sensible measures include stopping smoking (again) keeping one’s weight down, and a bit of exercise. Scientifically, some of that advice is productive: some is prudent.
I had this column checked out by a cancer specialist, and asked him for a (non-hysterical) approach to prostate cancer. He told me it would be prudent to consult your doctor for any continuing urinary problems. And if your GP suggests a rectal examination as part of routine examination, take it like a man.
Added in August 2002 Despite there have been considerable advances in our understanding of prostate cancer in the last decade, and some advances in treatment, the basic themes and advice in this column remain as true today as it did when it was written.
For further information visit New Zealand Cancer Society