I have been quiet as a columnist for several months, swept away by the demands of practice and research. But last weekend, my mentor who keeps me updated with the latest science sent me a freshly updated Cochrane Review, one of the world’s most trusted forms of independent scientific evidence synthesis. While I was planning to rest, I found myself completely unable to stop digesting it. The stakes for our community are too high and I have to say my piece.
The Cochrane review focuses on the prostate-specific antigen test, better known as the PSA test, a blood test used to screen for prostate cancer. Pooling data from nearly 790,000 men, the researchers have revised their earlier conclusions from 2013. They now show that systematic PSA screening likely reduces the risk of dying from prostate cancer and may also reduce the risk of dying from any cause. In actual numbers, screening prevents about 2 deaths specifically from prostate cancer and can avert up to 5 deaths overall for every 1,000 men tested.
But this survival benefit comes with a heavy catch. Screening also significantly inflates diagnoses, adding about 36 extra prostate cancer cases per 1,000 men. Many of these are early, slow-growing tumours that might never have shortened a man’s life or caused symptoms. Crucially, the review notes that we still have insufficient evidence on the long-term, downstream harms caused by this wave of extra testing and treatment.
Predictably, this news will cause excitement. Global health systems and healthcare professionals will rush to re-ignite an old debate: should we screen all men or shouldn’t we? But before we in Malaysia jump into this debate, there is a bigger issue we need to confront. It has everything to do with what I call the “foreign gaze.”
A foreign gaze is what happens when a society looks at itself through the eyes of an outsider, mistakenly assuming the outsider’s reality is the universal standard. In medicine, we fall into this trap all the time. When you look closely at that massive study of 790,000 men, a glaring truth emerges: the vast majority were White, living in Europe and North America. Their genetics, lifestyles and health systems belong to a very different world.
If we take their clinical findings and copy-paste them directly into Malaysia, we are viewing our own grandfathers, fathers and brothers through a foreign gaze. It is like buying a heavy winter coat designed for a London blizzard and expecting it to make sense in Kuala Lumpur. It is evidence transfer, not evidence-based medicine.
If we want to protect our population, the debate should not be a simple “yes or no” to screening. It should be about whether our healthcare system is ready. To figure that out, we must ask five hard questions.
1. Do we know our own numbers?
Before we invite thousands of healthy men to get tested, we need reliable local data. We need to know how many Malaysian men get prostate cancer, at what age and at what stage, broken down by our diverse ethnic groups. Without our own arithmetic, a national screening policy is guesswork.
2. Do we know our own populations?
Western trials tell doctors what PSA level should trigger alarm. But those thresholds were largely derived from studies dominated by Western populations. Can we assume that Malay, Chinese and Indian men share the same biological baselines or genetic risks? The truth is, we do not yet know what truly applies to us.
3. Can our health systems handle what screening finds?
A screening test is not just a blood test; it is the start of a long medical journey. A man with a high PSA reading needs timely biopsy, accurate lab analysis and affordable treatment. If our public clinics and hospitals are already stretched and cannot provide those steps quickly, we have not created a screening programme. We have created pressure in the system and fear and uncertainty for the patient.
4. Who bears the harms?
In affluent Western countries, the fear is overdiagnosis: treating a slow-growing tumour so aggressively that a man suffers incontinence or erectile dysfunction for a cancer that would never have killed him. But in Malaysia, where many patients still present late, our urgent crisis is also underdiagnosis. The risks and benefits look different depending on where you live.
5. Who is generating our evidence?
If the answer is “too few of us, too inconsistently and not close enough to policy,” then that is the political and health problem we need to fix first.
We must stop being passive consumers of external data to govern our local bodies. True medical independence means generating our own data and building systems that fit our own reality.
And while I am using prostate cancer as the example here, the point applies across cancer control. Whether we are talking about lung, breast, colorectal or other cancers, imported evidence cannot be applied responsibly without asking whether it fits our population, our health system and our realities.
But as another mentor of mine rightly pointed out when I shared these thoughts, skepticism alone cannot be the end goal. The way forward is not to sit on our hands until we have a flawless national solution. It is to roll up our sleeves and build better care systems one state or even district at a time.
We cannot let the daunting challenge of scale become our excuse for doing nothing. Until we drop the foreign gaze and look at our own health system in the mirror, our most responsible choice is not paralysis. It is locally grounded action.
