Does anyone here know about Prostate Artery Embolization (PAE)? Is it available in Thailand?

I have no idea if this technique is available in Thailand.

You should open and read the content of the link.

http://www.medscape.com/viewarticle/841963

There are farangs going to Delhi for this op ,about £900,but down to Chennai,which basically is a medical city alongside the actual city,it is being done for around £350,just been over to have prostate done starting at £175 ,cancelled it for this one,when Ill do it? maybe in few months time

Hopefully you'll consult a doctor and consider medical solutions before deciding something new must be better and you need to differentiate BPH from prostate cancer when considering the approach to treatment.

I started on Flomax a couple of months ago (in Thailand sold as Harnal OCAS once a day tablets). Almost immediate improvement and after the first month a big improvement. The only negative side effect I experienced was some fatigue the first week. No other problems. Now can sleep through the night with no visits to the loo or, at most, one visit if I consumed too much coffee and tea late at night.

Prostate artery embolization appears to be a safe and effective alternative to more traditional treatments for benign prostatic hyperplasia, according to two new studies.

"Although it's not going to replace surgery, it'll have a definite role," Bhaskar Somani, MD, from University Hospital in Southampton, United Kingdom, toldMedscape Medical News.

It might be a stop-gap measure, especially for young men, until they need surgery. "The results are very good and very promising," said Dr Somani before he presented results from his team's study here at the European Association of Urology 30th Annual Congress.

"Prostate artery embolization is a feasible and minimally invasive technique," said Giorgio Ivan Russo, MD, from the University of Catania in Italy, who presented his team's study of the procedure.

However, the procedure is associated with persistent symptoms at 1 year and "should be performed in very select patients," Dr Russo added.

http://www.medscape.com/viewarticle/841963

Hopefully you'll consult a doctor and consider medical solutions before deciding something new must be better and you need to differentiate BPH from prostate cancer when considering the approach to treatment.

I started on Flomax a couple of months ago (in Thailand sold as Harnal OCAS once a day tablets). Almost immediate improvement and after the first month a big improvement. The only negative side effect I experienced was some fatigue the first week. No other problems. Now can sleep through the night with no visits to the loo or, at most, one visit if I consumed too much coffee and tea late at night.

Prostate artery embolization appears to be a safe and effective alternative to more traditional treatments for benign prostatic hyperplasia, according to two new studies.

"Although it's not going to replace surgery, it'll have a definite role," Bhaskar Somani, MD, from University Hospital in Southampton, United Kingdom, toldMedscape Medical News.

It might be a stop-gap measure, especially for young men, until they need surgery. "The results are very good and very promising," said Dr Somani before he presented results from his team's study here at the European Association of Urology 30th Annual Congress.

"Prostate artery embolization is a feasible and minimally invasive technique," said Giorgio Ivan Russo, MD, from the University of Catania in Italy, who presented his team's study of the procedure.

However, the procedure is associated with persistent symptoms at 1 year and "should be performed in very select patients," Dr Russo added.

http://www.medscape.com/viewarticle/841963

For every negative notice pulled off the net ,could put another 10 (at least)in opposite direction The "persistent symptoms" were actually non-events in the scheme of things. I'm not taking drugs for this problem,taken them and a total waste of time.

Looks as a 30% reduction in prostate size is achieved in most circumstances,which is ideal

Hopefully you'll consult a doctor and consider medical solutions before deciding something new must be better and you need to differentiate BPH from prostate cancer when considering the approach to treatment.

I started on Flomax a couple of months ago (in Thailand sold as Harnal OCAS once a day tablets). Almost immediate improvement and after the first month a big improvement. The only negative side effect I experienced was some fatigue the first week. No other problems. Now can sleep through the night with no visits to the loo or, at most, one visit if I consumed too much coffee and tea late at night.

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..Worth considering medication-wise is Cardura XL (Doxazosin) as an alternative to Harnal which can/does affect dysfunction in a lot of cases.

Cardura XL is a 'fraction' of the cost of Harnal..worth considering too and has 'hypertension' lowering compounds as well...PSA tests support my changing from Harnal to Cardura....hope this assists!

Hopefully you'll consult a doctor and consider medical solutions before deciding something new must be better and you need to differentiate BPH from prostate cancer when considering the approach to treatment.

I started on Flomax a couple of months ago (in Thailand sold as Harnal OCAS once a day tablets). Almost immediate improvement and after the first month a big improvement. The only negative side effect I experienced was some fatigue the first week. No other problems. Now can sleep through the night with no visits to the loo or, at most, one visit if I consumed too much coffee and tea late at night.

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

..Worth considering medication-wise is Cardura XL (Doxazosin) as an alternative to Harnal which can/does affect dysfunction in a lot of cases.

Cardura XL is a 'fraction' of the cost of Harnal..worth considering too and has 'hypertension' lowering compounds as well...PSA tests support my changing from Harnal to Cardura....hope this assists!

Thanks for info RodC,would that be Doxazosin 2mg ? This is what I am using. Was treated for prostrate cancer in UK...Hormone and 20 sessions of Radio Therapy10 years ago, no problems since,other than one trip to bathroom,in cool season(no sweating)in day.

Hopefully you'll consult a doctor and consider medical solutions before deciding something new must be better and you need to differentiate BPH from prostate cancer when considering the approach to treatment.

I started on Flomax a couple of months ago (in Thailand sold as Harnal OCAS once a day tablets). Almost immediate improvement and after the first month a big improvement. The only negative side effect I experienced was some fatigue the first week. No other problems. Now can sleep through the night with no visits to the loo or, at most, one visit if I consumed too much coffee and tea late at night.

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

..Worth considering medication-wise is Cardura XL (Doxazosin) as an alternative to Harnal which can/does affect dysfunction in a lot of cases.

Cardura XL is a 'fraction' of the cost of Harnal..worth considering too and has 'hypertension' lowering compounds as well...PSA tests support my changing from Harnal to Cardura....hope this assists!

Thanks for info RodC,would that be Doxazosin 2mg ? This is what I am using. Was treated for prostrate cancer in UK...Hormone and 20 sessions of Radio Therapy10 years ago, no problems since,other than one trip to bathroom,in cool season(no sweating)in day.

=========================

4mg daily and dysfunction a lot less..good luck!

Hopefully you'll consult a doctor and consider medical solutions before deciding something new must be better and you need to differentiate BPH from prostate cancer when considering the approach to treatment.

I started on Flomax a couple of months ago (in Thailand sold as Harnal OCAS once a day tablets). Almost immediate improvement and after the first month a big improvement. The only negative side effect I experienced was some fatigue the first week. No other problems. Now can sleep through the night with no visits to the loo or, at most, one visit if I consumed too much coffee and tea late at night.

Prostate artery embolization appears to be a safe and effective alternative to more traditional treatments for benign prostatic hyperplasia, according to two new studies.

"Although it's not going to replace surgery, it'll have a definite role," Bhaskar Somani, MD, from University Hospital in Southampton, United Kingdom, toldMedscape Medical News.

It might be a stop-gap measure, especially for young men, until they need surgery. "The results are very good and very promising," said Dr Somani before he presented results from his team's study here at the European Association of Urology 30th Annual Congress.

"Prostate artery embolization is a feasible and minimally invasive technique," said Giorgio Ivan Russo, MD, from the University of Catania in Italy, who presented his team's study of the procedure.

However, the procedure is associated with persistent symptoms at 1 year and "should be performed in very select patients," Dr Russo added.

http://www.medscape.com/viewarticle/841963

For every negative notice pulled off the net ,could put another 10 (at least)in opposite direction The "persistent symptoms" were actually non-events in the scheme of things. I'm not taking drugs for this problem,taken them and a total waste of time.

Looks as a 30% reduction in prostate size is achieved in most circumstances,which is ideal

Hardly a negative review. "appears to be a safe and effective alternative to more traditional treatments" It tempers irrational exuberance.

Some things work well for some people and do nothing (or worse) for others. There are certainly many negative reviews for Flomax, which is why I was initially reluctant to try it, but I thought it was better to start out with something relatively simple before moving on to anything invasive, even minimally invasive, that was irreversible. Obviously Flomax works quite well for many men or its continued use would have dropped off. And there are numerous other medicines that might be more appropriate.

Given the short period of time it's been available outside of clinical trials, deciding the persistent symptoms were actually a non-event is pretty premature.

You can try Permixon,a french med available in Thailand before having an invasive method (around 2000b/month) .See a urologist for advice

You can try Permixon,a french med available in Thailand before having an invasive method (around 2000b/month) .See a urologist for advice

Basically a saw palmetto herbal formulation.

May help with symptoms but that won't ever reduce the size of an enlarged prostate.

So does anyone know if this newer procedure is available anywhere in Thailand?

An issue with the traditional and turp surgery is potential incontinence and sexual damage. Not an issue with this newer thing.

I am nto aware of anyplace doing this yet in Thailand.

It is very new, in fact there are still clinical trials in progress to establish its long-term efficacy and risk profile compared to other approaches.

With this or any other new approach, you really don't want to be among the first few procedures performed at a facility. There is a learning curve. So even when it is first done here I wouldn't recommend rushing to get it right way. It will also likely be reserved for patients in whom conservative treatment (medications) has failed.

Note that in the UK study, while adverse effects were usually minor, one-third of men undergoing the procedure did not improve. So it is not a surefire cure. Research is still underway to compare its results to TURP and also to get a better handle on which patients are most likely to benefit from it.

A concern I'd have about traveling to India even to a place that may be very experienced with this new procedure is that there would be a strong bias to do it even if it's not really the best choice for the specific case. I suppose you could consult with a Thai doctor first before traveling but would they really be qualified to have an opinion either way and the Indian doctor would be biased to do it as that's what you're there for. Also my understanding is there's a one week recovery period of home rest so I assume that means you wouldn't want to fly during their time.

Trip was not wasted even though Green Light prostate surgery awaited.. advised red light...colonoscopy 600baht,down the throat 1200 baht,heart echocardography tested..800 baht (3 years ago LVID borderline,this time 64%,just what is borderline?) pages of blood testing half hour with thyroid doc,underactive thyroid,x rays,23 skin blemishes blasted 600 baht,before/after bladder test urology doc , I sure do need that op advised live another 50 years,not bad for 89 year old sat the week out then downing beer at third of Thai prices 7 thousand via KL

good week anyway got loads of veterinary meds fraction of prices here

Trip was not wasted even though Green Light prostate surgery awaited.. advised red light...colonoscopy 600baht,down the throat 1200 baht,heart echocardography tested..800 baht (3 years ago LVID borderline,this time 64%,just what is borderline?) pages of blood testing half hour with thyroid doc,underactive thyroid,x rays,23 skin blemishes blasted 600 baht,before/after bladder test urology doc , I sure do need that op advised live another 50 years,not bad for 89 year old sat the week out then downing beer at third of Thai prices 7 thousand via KL

good week anyway got loads of veterinary meds fraction of prices here

Well, that's nice, but can you shed any light on the situation with this specific prostate procedure in India?

Type the name of the surgery and then India

New Treatment for Enlarged Prostate Shows Fewer Side Effects.htm

Type the name of the surgery and then India

What is the name of the 'surgery ' ?

Type the name of the surgery and then India

What is the name of the 'surgery ' ?

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Enlarged Prostate (Benign Prostatic Hyperplasia)

• What is prostate gland ?
• Symptoms & causes of enlarged prostate
• Risk factor & complication of enlarged prostate
• Test & Diagnosis of Benign prostatic hyperplasia
• Surgical Treatment options
• Non-surgical treatment option
• Non surgical treatment vs. surgical treatment
• Best Solution – Prostatic Artery Embolization
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• F.A.Q.s
• Patient Success Stories
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• Other Non-surgical Treatment options

What is prostate gland?

The prostate is a walnut-sized gland located between the bladder and the penis. The prostate is just in front of the rectum. The urethra runs through the center of the prostate, from the bladder to the penis, letting urine flow out of the body.

The prostate secretes fluid that nourishes and protects sperm. During ejaculation, the prostate squeezes this fluid into the urethra and it’s expelled with sperm as semen.

The vasa deferentia (singular: vas deferens) bring sperm from the testes to the seminal vesicles. The seminal vesicles contribute fluid to semen during ejaculation.



As a man ages, there is a good chance that he will develop an enlarged prostate or benign prostatic hyperplasia (BPH). In fact, it is estimated that close to 80% of men will develop BPH. But more than 40% of men who develop an enlarged prostate will need surgery to correct symptoms from this enlarged prostate

Symptoms & causes of enlarged prostate (BPH)

• A weak or slow urinary stream
• A feeling of incomplete bladder emptying
• Difficulty starting urination
• Frequent urination
• Urgency to urinate
• Getting up frequently at night to urinate
• A urinary stream that starts and stops
• Straining to urinate
• Continued dribbling of urine
• Returning to urinate again minutes after finishing

When the bladder does not empty completely, you become at risk for developing urinary tract infections. Other serious problems can also develop over time, including bladder stones, blood in the urine, incontinence, and acute urinary retention (an inability to urinate). A sudden and complete inability to urinate is a medical emergency; you should see your doctor immediately. In rare cases, bladder and/or kidney damage can develop from BPH.

Most men have continued prostate growth throughout life. In many men, this continued growth enlarges the prostate enough to cause urinary symptoms or to significantly block urine flow. Doctors aren't sure exactly what causes the prostate to enlarge. It may be due to changes in the balance of sex hormones as men grow older.

Risk factor & complication of enlarged prostate (BPH)

Risk factor

• Aging. Prostate gland enlargement rarely causes signs and symptoms in men younger than 40. By 55, about 1 in 4 men have some signs and symptoms. By 75, about half of men report some symptoms.
• Family history. Having a blood relative such as a father or brother with prostate problems means you're more likely to have problems as well.
• Where you're from. Prostate enlargement is more common in American and Australian men. It's less common in Chinese, Indian and Japanese men.

Complication

Prostate gland enlargement becomes a serious problem when it severely interferes with your ability to empty your bladder. If this is the case, you'll probably need surgery. Complications of enlarged prostate include:

• Acute urinary retention. Acute urinary retention is a sudden, painful inability to urinate. This may occur after you've taken an over-the-counter decongestant medication for allergies or a cold. When you are unable to urinate at all, your doctor may thread a tube (catheter) through your urethra into your bladder. Or, your doctor may put in a suprapubic tube — a catheter that drains your bladder through the lower abdomen. The type of catheter you need will depend on your particular circumstances. Some men with an enlarged prostate require surgery or other procedures to relieve urinary retention.
• Urinary tract infections (UTIs). Some men with an enlarged prostate end up having surgery to remove part of the prostate to prevent frequent urinary tract infections.
• Bladder stones. These are mineral deposits that can cause infection, bladder irritation, blood in the urine and obstruction of urine flow and are generally caused by the inability to completely empty the bladder.
• Bladder damage. This occurs when the bladder hasn't emptied completely over a long period of time. The muscular wall of the bladder stretches and weakens and no longer contracts properly. Often, symptoms of bladder damage improve after prostate surgery or other treatment, but not always.
• Kidney damage. This is caused by high pressure in the bladder due to urinary retention. This high pressure can directly damage the kidneys or allow bladder infections to reach the kidneys. When an enlarged prostate causes obstruction of the kidneys, a condition called hydronephrosis — a swelling of the urine-collecting structures in one or both kidneys — may result.
• Most men with an enlarged prostate don't develop these complications. However, acute urinary retention and kidney damage in particular can be serious health threats when they do occur.

Test diagnosis of enlarged prostate (BPH)

• Detailed questions about your symptoms.
• Digital rectal exam. This exam can determine whether your prostate is enlarged or not.
• Urine test (urinalysis). It can help rule out an infection or other conditions that can cause similar symptoms.
• Prostate-specific antigen (PSA) blood test. It's normal for your prostate gland to produce PSA, which helps liquefy semen. When you have an enlarged prostate, PSA levels increase. However, PSA levels can also be elevated due to prostate cancer, recent tests, surgery or infection (prostatitis).
• Urinary flow test. This test measures the strength and amount of your urine flow.
• Post-void residual volume test. This test measures whether you can empty your bladder completely. This is often done by using an ultrasound test to measure urine left in your bladder.
• Transrectal ultrasound. An ultrasound test provides measurements of your prostate and also reveals the particular anatomy of your prostate.
• Prostate biopsy. With this procedure, a transrectal ultrasound guides needles used to take tissue samples of the prostate. Examining tissues from a biopsy under a microscope can be help diagnose or rule out prostate cancer.
• Urodynamic studies and pressure flow studies. With these procedures, a catheter is threaded through your urethra into your bladder. Water (or less commonly air) is slowly injected into your bladder. This allows your doctor to measure bladder pressures and to determine how well your bladder muscles are working.

Prostate cancer is entirely different than prostate gland enlargement, even though they can cause some similar symptoms and may be detected by some of the same tests. Having an enlarged prostate doesn't reduce or increase the risk of prostate cancer. Even if you're being treated for an enlarged prostate gland, you still need to continue regular prostate exams to screen for cancer.

Surgical Treatment Options for Benign prostatic hyperplasia (BPH)

There are many treatment options exist. Many men experience no signs or symptoms with enlarged prostate. If that's the case for you, watchful waiting could be the best option. Enlarged prostate aren't cancerous.

• transurethral resection of the prostate (TURP)
• Open prostatectomy
• Laser surgery

Surgical: - Transurethral resection of the prostate (TURP)

TURP has been a common procedure for enlarged prostate for many years, and it is the surgery with which other treatments are compared. With TURP, a surgeon places a special lighted scope (resectoscope) into your urethra and uses small cutting tools to remove all but the outer part of the prostate (prostate resection). TURP generally relieves symptoms quickly, and most men have a stronger urine flow soon after the procedure. Following TURP, there is risk of bleeding and infection, and you may temporarily require a catheter to drain your bladder after the procedure. You'll be able to do only light activity until you're healed.

TURP required the doctor to insert a device up the urinary tube and remove the prostate, as pieces at a time. This procedure was found to be effective at stopping the symptoms. But there were complications from this type of procedure. Such as erectile dysfunction, blood in the urine, blood loss even few days after surgery, water intoxication and urinary incontinence. Also TURP could only be performed on prostates that are 60 cubic centimeters in size or less.

Open prostatectomy

This type of surgery is generally done if you have a very large prostate, bladder damage or other complicating factors, such as bladder stones. It's called open because the surgeon makes an incision in your lower abdomen to reach the prostate. Open prostatectomy is the most effective treatment for men with severe prostate enlargement, but it has a high risk of side effects and complications. It generally requires a short stay in the hospital and is associated with a higher risk of needing a blood transfusion.

Laser surgery

Laser surgeries (also called laser therapies) use high-energy lasers to destroy or remove overgrown prostate tissue. Laser surgeries generally relieve symptoms right away and have a lower risk of side effects than does TURP. Some laser surgeries can be used in men who shouldn't have other prostate procedures because they take blood-thinning medications.

Any type of prostate surgery can cause side effects, such as semen flowing backward into the bladder instead of out through the penis during ejaculation (retrograde ejaculation), loss of bladder control (incontinence) and impotence (erectile dysfunction).

Non-surgical: - A. Prostatic artery embolization(PAE)

Now a new procedure has been developed that is comparable to TURP in recovery the symptoms with no side effect. It is called Prostatic Artery Embolization or PAE.

The patients were admitted to the hospital on the day of the procedure after all basic investigation. During embolization, pain medication, anti-inflammatory drugs and antibiotic were given.

Embolization was performed under local anesthesia by unilateral approach, usually the right femoral artery. Initially, pelvic angiography was performed to evaluate the prostatic arteries. Then, a 4 or 5-F angiography catheter was introduced reach in prostatic artery and a 3-F coaxial microcatheter advance in the ostium of the prostatic artery. For embolization, nonspherical PVA particles were used. The endpoint chosen for embolization was slow flow or near-stasis in the prostatic vessels with interruption of the arterial flow and prostatic gland opacification.

When embolization of the both prostatic arteries was finished, the catheter was removed. After 4- 6 hrs patients can start walking around in room without a urinary catheter. Same day he can resume the normal activities.

Picture 1: - Angiographic picture in a 74-year-old patient with urinary retention with a bladder catheter. Before and after Prostatic Artery Embolization.

Picture 2: - Pelvic MR images in a 78-year-old patient with BPH. Before PAE shows an enlarged prostate diameter of 59.2 mm and a prostate volume of 95.5 m. After 6 months of PAE shows significant reduction in size.

Advantages of Prostatic Artery Embolization ( PAE)

• PAE can be performed on any size enlarged prostate.
• It does not produce the side effects/complication that TURP does.
• Whole procedure done through a small nick around the skin in the groin region.
• Most men experience no pain to light pain and leave the hospital in a day after intervention.
• No sexual dysfunction following prostatic artery embolization.
• Quarter of patient report that sexual function improved after the procedure.
• PAE procedure need no general anesthesia it need just mild to sedation,
• No blood loss or risk of blood transfusion.
• No surgical ugly scars and makes for faster recovery.
• It is cheaper than surgery.
• Overall success rate is about more than 98%.

Non surgical treatment vs. surgical treatment

Best solution - Non surgical treatment - Prostatic artery embolization

What it isProstatic artery embolization (PAE) is a procedure where an interventional radiologist uses a catheter to deliver small particles that block the blood supply to the enlarged prostate. The procedure is not a surgical intervention and allows the all function of prostate to be kept in place. After embolization the shrinkage of an enlarged prostate in 2-3 weeks time.

Why PAE is the best option

• PAE can be performed on any size enlarged prostate.
• It does not produce the side effects/complication that TURP does.
• Whole procedure done through a small nick around the skin in the groin region.
• Most men experience no pain to light pain and leave the hospital in a day after intervention.
• No sexual dysfunction following prostatic artery embolization.
• Quarter of patient report that sexual function improved after the procedure.
• PAE procedure need no general anesthesia it need just mild to sedation,
• No blood loss or risk of blood transfusion.
• No surgical ugly scars and makes for faster recovery.
• It is cheaper than surgery.
• Overall success rate is about more than 98%.

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....& improved sexual function,hell now were cookin'

Did my own little research on this procedure. 

 

It appears to be quite challenging for the radiologist as he has to navigate a cobweb of arteries, the configuration of which varies from patient to patient. The main risk being the release of the pellets into the bloodstream supplying the bladder or the rectum, hence damaging these organs... scary.

 

Wondering I'd go to India to an unknown hospital for such a procedure. 

 

Hopital Claude Pompidou, in Paris, seem to have a good background in PAE though, probably plenty of places in US too.

I’ve been using Xatral XL 10mg for a few years with great results and no noticeable side effects.

Went from getting up every hour to sleeping the night though.


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There's a newspaper article in a UK newspaper today about prostate artery embolization. I'd post a link but it's behind a paywall.

 

It says “Currently the treatment is only available at 18 NHS centres, as part of research trials.” However it goes on to say it should be more generally available in the UK on the NHS within about two years. It also notes "The procedure is likely to cost the NHS around £2,500 per patient, in line with the costs of surgery, with possible savings from shorter hospital stays."

 

Has anyone heard anything recently about prostate artery embolization being available in Thailand?

Try this :

 

https://www.telegraph.co.uk/news/2018/04/24/pioneering-prostate-treatment-gets-nhs-green-light/

No and given how new it is and still in research phase it will likely be quite some years before it is.

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On 4/9/2016 at 8:01 AM, loppylugs1 said:

For every negative notice pulled off the net ,could put another 10 (at least)in opposite direction The "persistent symptoms" were actually non-events in the scheme of things. I'm not taking drugs for this problem,taken them and a total waste of time.

Looks as a 30% reduction in prostate size is achieved in most circumstances,which is ideal

It took me eight months to jump over my own shadow and visit the local hospital three days ago.

They found a few important blood related issues, did an X-ray where I saw an extreme problem at my spine after a guy had almost killed me in an accident.

 

My next appointment is on the 30th, where they told me to make a "cancer blood test." If anybody has such a problem it's always better to see a doctor fist, even when it's a sort of inconvenient. 

 

  I can only hope that the blood test isn't positive. Does anybody know how and what they test? Are they looking for cells that aren't ordinary ones? Thanks. 

Hopefully it is a PSA as pretty much all other blood tests it migjt be are not suitable as screening tools (some hospitals still do them becsuse from their point of view all the resulting false positives are a plus as they lead to expensive unnecessary procedures).

Find out what the test is and if other than PSA do not agree unless they can give you a specific reason such as other abnormal finding.

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9 minutes ago, Sheryl said:

Hopefully it is a PSA as pretty much all other blood tests it migjt be are not suitable as screening tools (some hospitals still do them becsuse from their point of view all the resulting false positives are a plus as they lead to expensive unnecessary procedures).

But Sheryl my understanding, so far, was that the PSA was acceptably sensitive but not selective at all. Hence the debate about its use for systematic screening...