Resisting the screening imperative: patienthood, populations and politics in prostate cancer detection technologies for the UK

The introduction of mass screening programmes in the UK has been controversial. It is instructive to examine medical conditions for which screening has been actively considered but not introduced, such as prostate cancer. Incidence of the disease has escalated during the last 20 years, partly due to the upsurge in use of PSA (prostate-specific antigen) detection technology. The controversy is moving into a new phase, associated with the development of new molecular genetic biomarkers and tests derived from genome-association studies. The paper outlines the most recent scientific and technological developments for the three types of detection technology – PSA, genetic, and genomic. Applying concepts of risk, technology governance and technology expectations, it is shown that central public health governance actors continue to resist the tidal wave of new technologies through a variety of increasingly diverse governance modes. In the case of PSA, a governance trend moving beyond ‘responsibilisation’ to citizen rights is shown, whereas in the case of genetic tests and genomic risk profiling, state public health agencies are shown to be engaging in a form of technology expectation management, as it responds to a new marketplace of private commercial testing and mediatised science-based visions of future healthcare

Identifying Effectiveness in 'The Old Old': Principles and Values in the Age of Clinical Trials

This article explores some implications of the increasing reliance on clinical trials in contemporary health care, particularly health care payers efforts to use them in the so-called fourth hurdle decisions. How do these agencies manage medical uncertainty given the desire to produce clear guidelines for clinicians? Their solutions take account of trials in at least two ways, reflecting broader debates about the meaning of these medical experiments. Trials can be read as either proofs of protocol, straight-forward guides to action with individual drugs in specific populationsor proofs of principle where extrapolation is made possible through an appeal to underlying biological mechanisms. These contrasting readings of trials are illustrated with reference to guidelines on heart disease prevention/cholesterol reduction using statins among the elderly in North America and the United Kingdom. Uncertainty in these cases does not lead to inertia but solutions use different fixed points to aid navigation, including both physiological principles and moral values