Wer sorgt hier vor?

[A time of change for men's health: a process of increasing medicalisation?]

These days, men suffer from a bad reputation when the media talk about health matters. Nonetheless, talking about men's health is problematic, as it considers the health behaviour of the male gender in an essentialistic manner. Such discourse is socially under-differentiated, frequently dramatises the gender difference rather than explaining it, makes inappropriate individualisations, draws on questionable benchmarks, makes women the positive model without first reflecting, and is ahistorical. Gender patterns have a major significance for health behaviour and have indeed considerably changed the health behaviour of men and women over the last 250 years. Women have been more seriously medicalised and have, on account of their life expectancy, profited more from modernisation, developments in hygiene, the expansion of medical services and state healthcare policies. However, over the last 30 years, besides a continuing parallel medicalisation of men, signs of it increasing can also be seen. Their behaviour has become more compatible with health. A more adequate description of the situation could be achieved through a more concentrated observation of health lifestyles.

[Early detection of prostate cancer: harm verified, benefit not verifiable]

The results of randomized studies on the early detection of prostate cancer and those of a systematic Cochrane review are compiled and interpreted. Some fundamental and inherent weaknesses of screening studies are pointed out and discussed. The meta-analysis of studies involving a total of 321,594 participants shows no reduction in prostate cancer mortality or all-cause mortality, but describes disadvantages such as unnecessary biopsies, overdiagnosis, and overtreatment. A relevant increase in overall mortality cannot be excluded. Even in future trials, the possible reduction of prostate cancer mortality or all-cause mortality by prostate cancer screening will not be detectable because of inherent methodological problems, e.g., an extremely high number of participants are needed. Furthermore, by nature, studies on the early detection of cancer last very long, such that the results are inevitably outdated at the end of the study. There is a risk that studies on the early detection of cancer suggest an advantage and at the same time overlook a relevant increase in overall mortality. Prostate cancer screening also ignores important WHO criteria for screening programs: There is evidence that early treatment of prostate cancer is not better than late treatment. There is no suitable or reliable test to identify the early stages of the disease. The benefit-risk ratio is not clearly favorable, and there is doubt whether the costs and the benefits are in an acceptable balance. There are valid reasons to advise against population-based prostate cancer screening.

[Cancer screening: curative or harmful? An ethical dilemma facing the physician]

Early detection based on prostate-specific antigen (PSA) presumably can reduce prostate cancer mortality. At the same time it is associated with a comparatively high rate of overdiagnosis involving tumors that would not have become apparent without screening since they would have remained asymptomatic during the patient's entire life. Current studies show that the probability of such an overdiagnosis is 12-48 times higher than one which would save a man's life. Thus, overdiagnosis poses an ethical dilemma for physicians: their actions (screening examination) can turn a healthy individual into a chronically ill person. This profoundly contradicts the principle of medical ethics to"do no harm." An open debate on whether early detection can be reconciled with doctors' ethical duties is hampered by the implications of liability law, faulty economic incentives, and the pressures of competition as well as the empirical practice of many physicians to overestimate the benefits of cancer screening.