Abstract
The underfunding of upstream interventions (prevention and screening) is often seen as a mistake, for the least. However, whatever your moral theory might be, reallocation in favor of very early detection is questionable. From a deontological perspective and according to the rule of rescue described by Al Jonsen in its contribution “Bentham in the Box” a society should look first at helping the threatened ones (the affected ones) whether it is cost-effective or not. Spending “more” money for treatment would therefore be the result of a self-imposed moral duty. In contrast screening and even more prevention, appear to be, in this perspective less mandatory. However for utilitarian advocates, looking for the “best” allocation is looking for the most cost-effective one and prevention, screening and care be assessed/compared without that kind of moral bias.
In this perspective, it is useful to make a clear distinction between early diagnosis and screening. According to the quantitative relationship between stages and survival, more than the 2/3 of what could be gained lay in a shift from stage II to stage I, and not a in a shift from stage I to an earlier state. This latter attempt would be costly with few returns (the standard neoclassical production function with decreasing returns). Therefore, allowing every stage II case to be diagnosed at stage I, will yield more benefits and more equity (distributive justice). Even more, if we can be confident in expecting that almost every tumor of 2 cm will grow and spread, in contrast the natural history of a very small tumor will be more heterogeneous. Which screened small prostate cancers will be threatening (or not) is a key question. I believe that new biological markers will give us that critical information, and for that matter, that biological paradigm of cancer (the kind of the tumor) will overcome the anatomical paradigm (the size of the tumor).
Lastly, even if the pace of discovery for screening tools might be fast and full of promises, to understand the growing interest in screening programs it would be useful to have also a sociological perspective considering the rise of a surveillance medicine (M. Foucault and D. Armstrong).
Citation Information: Cancer Prev Res 2011;4(10 Suppl):B1.