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Archive for the ‘Govt prostate policy’ Category

PROSTABLOG NZ: If you’re Maori and poor in New Zealand, you have less chance of being diagnosed early with prostate cancer – and you’re got a 60% greater chance than non-Maori of dying .

These and other findings are in a major new report just released by the NZ Ministry of Health, whose researchers looked at cancer trends in the five years 2002 to 2006 and compared rates with ethnicity (Maori and non-Maori) and socio-economic status (deprivation) and where people live.

Some quotes from the report:

Prostate cancer was…more common among non-Māori men, but Māori death rates were higher than those of non-Māori men.

On average, just over 130 Māori men were diagnosed with prostate cancer each year, and around 33 died from the disease during 2002–2006.

Among non-Māori men, on average 2,495 per year were diagnosed with prostate cancer and nearly 540 per year died from the cancer.  The Māori age-standardised registration rate was about 10% lower than the non-Māori rate while the death rate was 60% higher.

Over the period 1996–2006, there were no significant changes in incidence or mortality for Māori men.  Among non-Māori men there was no change in incidence but there was a significant decrease in mortality of 2% per year.

Prostate cancer incidence was associated with increasing deprivation for Māori men but not for non-Māori.

Prostate cancer incidence was significantly lower among Māori and non-Māori rural residents compared to main urban residents.

Only a small proportion of lung, prostate cancers and around a third of stomach cancers were diagnosed at the earlier stages of disease spread.

…Māori had significantly lower odds than non-Māori of being diagnosed at a localised stage, and higher odds of being diagnosed at a distant stage for most of the key cancers (breast, cervical, colorectal, lung, and prostate cancers).

During the period 1996–2006, Māori had a significantly higher age-adjusted risk of dying from their cancer after diagnosis compared to non-Māori…The relative risks ranged from 24% higher for lung and stomach cancers to 103% higher for prostate cancer.

For prostate cancer, gaps between Māori and non-Māori are wider outside main urban centres.  Both Māori and non-Māori with prostate cancer have worse survival outcomes outside main urban centres, but the difference is greater for Māori patients.

Among non-Māori, increasing deprivation was significantly associated with poorer survival chances for breast, colorectal, lung, prostate, and uterine cancers.

Among Māori, rural residents had significantly lower survival (or higher death rates) than their main urban counterparts for prostate and uterine cancers.  Among non-Māori, rural residents had significantly lower survival from colorectal, lung, and prostate cancers.

Within each rural–urban area, Māori had higher risk than non-Māori of dying from their cancer after diagnosis.

Disparities in cancer incidence and outcomes persist in Aotearoa/New Zealand, although there is promising movement towards equity for specific cancers, such as cervical cancer.

…ethnic disparities in socioeconomic status and in other social and environmental determinants of health result from the entrenched unequal power relations that underpin and sustain a racialised society.

…there is some evidence to suggest that socio-economic inequalities in cancer mortality are growing over time.

Similarly to mortality trends, there is some suggestion of increasing socio-economic disparities in survival in recent decades.  Improvements in survival are generally larger for those people residing in affluent areas compared to those living in deprived areas for many cancers.

…participants in studies of Māori health care experiences report significant hardships resulting from the hidden costs of ‘distance deprivation’ among rural residents, particularly for those with low incomes.

For Māori, the age-sex-standardised incidence rate for all cancers combined was 220.4 per 100,000, 19% higher than the non-Māori rate of 185.2 per 100,000.  The cancer death rate for this period was 112.0 per 100,000 for Māori, 78% higher than the rate for non-Māori of 63.3 per 100,000 (Figure 2.1).

Lung cancer was the most commonly occurring cancer for Māori overall, accounting for 20% of all cancers (compared to 9% for non-Māori).  Breast, prostate, colorectal, and stomach cancers were the next most frequent.

Among non-Māori, the most common types were colorectal, prostate, breast, melanoma of the skin, and lung cancer.  These patterns were also consistent across each rural–urban area, except for non-Māori in rural areas where prostate ranked highest and melanoma third.

Among Māori males, lung cancer (20%) and prostate cancer (20%) were the most common (registrations), followed by colorectal (9%), stomach (5%) and liver cancer (5%).  For non-Māori males, prostate cancer was the most common (28%)…

Lung cancer was the leading cause of cancer death, accounting for 31% of Māori and 17% of non-Māori cancer deaths.

Female breast, colorectal, stomach and prostate cancers were the next most common for Māori. Among non-Māori males, lung, colorectal, prostate, cancers of unknown primary site, and melanoma were the leading causes of cancer death.

Among Māori, lung, breast, prostate and colorectal were the four leading cancer sites across all deprivation quintiles, with some variation across quintiles. Prostate, colorectal, breast, melanoma and lung were the five leading sites for non-Māori in all quintiles, with colorectal leading in the three most deprived quintiles.

Among non-Māori, the deprivation gradients were steepest for deaths from cervical, oral, and lung cancers.  Other cancers with a significant deprivation gradient for non-Māori included cancers of the thyroid, liver, stomach, uterus, pancreas, bladder, oesophagus and prostate.

Our results suggest that substantial undercount of Māori cancer registrations still exist, despite the improvement in the count of Māori registrations from the new ethnicity algorithm.  The undercount ranges from approximately 2% to 22% depending on age.

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PROSTABLOG NZ: The ideological debate about prostate cancer screening hasn’t moved along much in New Zealand over the past few years.

I’m judging this from an anecdote a guest speaker at my journalism course told students this week.

An experienced journalist, she said a few years ago she was writing a piece for NZ Listener magazine about PSA screening, and the Ministry of Health would speak to her only on the condition they got to see the resulting article prior to publication.

That usually causes journalists to feel apprehensive, and in this case her fears were realised.

The Ministry people hit the roof over what she wrote (basically, that all men over 50 should be urged to get PSA tests), and made this plain to her editor.

Judging by what I heard from the Ministry team at the Health Select Committee hearing into prostate cancer screening late last year, the official view is still the same: PSA bad.

Speaking of which – I wonder when we’re going to hear anything further from the committee?

Chairman Paul Hutchison made the MOH people promise to deliver their final views last November.

Did they?

Are there more hearings?

When will we see the results?

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PROSTABLOG NZ: Rates of prostate cancer detected in NZ are expected to rise about 23% in the decade leading up to 2016, moving from 91 cases per 100,000 to 112.

That’s the finding of a Ministry of Health cancer projection report released late last month, but only just picked up by news media (none of whom looked in detail at prostate cancer).

Something the report calls the “burden of new cases” is expected to increase by 71% over the 2006-2016 period. This term is not explained (for the uninitiated).

Interpreting the report is something of a challenge.

The Ministry’s researchers have chosen to single out prostate cancer projections as the only ones that “could not be updated  (although they have been extended), as these are based only on data up to 1984-88″.

The reason given is something they dub the “PSA effect”.

It’s hard to be sure, but this apparently means that because of a sudden upsurge of PSA testing in the late 1980s and early 1990s – leading to perhaps half of the Kiwi aged male population getting tested – there has been a massive blip in the detection statistics.

A half generation of men who would otherwise have not been detected until symptoms showed at an older age have been diagnosed “early”.

This has distorted trends to such an extent, it seems, the projection models can’t cope.

Graphs from the report, reproduced here, show the “bulge” effect. In the bottom one, the solid lines showing rates up to 2006 are extrapolated out (dotted lines) from 1986, ignoring what really happened because of PSA testing:

The Ministry says until rates return to what would have been expected “pre-PSA”, it cannot provide reliable predictions.

Despite that constraint, it has a go anyway: it concludes the rate of prostate cancer will continue to rise (presumably because of the baby boomer bulge moving through).

Confused? Join the club.

Why is prostate cancer being dealt with differently from other cancers that have been the subject of widespread screening and marketing campaigns, such as breast and cervical?

Is it because those screening campaigns were Ministry-approved, while PSA is frowned on by the Ministry because it leads to a problem – once prostate cancer is found there is no reliable way to know if it needs treatment, leading to possible over-treatment, and with it, unnecessary cost on the health system.

It would be useful to hear from epidemiologists on this, despite their inherent bias against PSA testing casting doubt on their views.

Still, they might help unravel the technicalities of the Ministry’s convoluted explanation.

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mohPROSTABLOG NZ: Maori and Pacific people living in NZ suffer big disparities in the way cancer is detected and treated, and how well they survive it. READ MORE>

This has been known for some time, but the problem is newly highlighted in the Ministry of Health-funded cancer guidelines for GPs that have just been released.

For example, it reminds us that as many as 17% of Maori cancer cases and 6% of deaths are never reported.

It also points out that health statistics tend to be five years old before they are published, which suggests that in the rapidly changing detection/treatment environment for prostate cancer, decision-making on how best to screen and treat is seriously hampered by lack of knowledge.

While the overall, 174-page report, avoids discussion of population-based screening, it does touch on the issue in the ethnicity section:

Cormack et al. noted that national screening programme data have identified that equitable screening for breast and cervical cancer has not been achieved for Mäori women.

However, BreastScreen South Limited’s results (70% of eligible Mäori women screened in 2005) suggest that the inclusion of focused efforts and leadership are the key to achieving equity in screening.

The report analyses available data on ethnic disparities in cancer detection and treatment, and makes a number of suggestions, including more “cultural competence” training for health workers.

For the full report, CLICK HERE>

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mohPROSTABLOG NZ: New guidelines for general practitioners on how to handle men presenting with possible symptoms of prostate cancer (and other cancers) were released today by the NZ Ministry of Health.  READ MORE> and HERE (summary)>

The advice is contained in a 174-page report from the Ministry-backed NZ Guidelines Group called Suspected Cancer in Primary Care – Guidelines for investigation, referral and reducing ethnic disparities, which sets out background data and guiding principles on a range of cancers.

The report avoids getting into population-based screening – a major issue in detecting prostate cancer – saying:

Cancer screening, health promotion and prevention, case-finding in asymptomatic people, recurrence of a previous cancer and metastatic cancer were beyond the guideline scope and therefore are not included.

However, it does relent a little in the section on ethnicity and cancer treatment disparity:

Addressing the issue of cancer screening is outside the broad scope of this guideline. However, because of the impact that screening uptake can potentially have on disease outcomes, it is briefly included as part of this disparity chapter.

In the section on prostate cancer, it outlines the following advice for GPs seeing patients:

  1. A man presenting with macroscopic haematuria (blood in urine) should be referred urgently to a specialist;
  2. A man found to have an enlarged, smooth prostate on digital rectal examination and a normal PSA should only be referred to a specialist if they have macroscopic haematuria;
  3. An older man presenting with lower urinary tract symptoms (frequency, hesitancy, nocturia) should be recommended to have a digital rectal examination and a PSA test.

Men with erectile dysfunction are excluded from the referral guidelines.

The report also contains the latest data on cancer trends and explores in some depth the detection, care and mortality disparities between Maori, Pacific people and European Kiwis.

On the page listing organisations that endorse the report (so presumably have seen it already), the Cancer Society of NZ (which opposes population-based prostate cancer screening) is included – but not the Prostate Cancer Foundation of NZ (which supports it).

The report comes just a week before the Government’s Parliamentary inquiry into prostate cancer detection and treatment, which will hear its first submissions on Wednesday.

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PROSTABLOG NZ: A new $20 million “Maori health innovations fund” has been announced by the Associate Minister of Health, Tariana Turia – but it makes no mention of one of the biggest killers of Maori men, prostate cancer.

The press release says:

The Fund is a significant step toward realising the aspirations of He Korowai Oranga (the Māori Health Strategy) and advancing whānau ora by supporting Māori service providers to develop and implement initiatives that effectively meet the health needs of whānau, hapū, iwi and their wider communities.

Over the next four years the Fund will invest a total of $20 million in the design, development, promotion and delivery of innovative whānau ora driven health services.

Check this site now for more information about the Māori Health Innovation Fund.

Download the Guide to Te Ao Auahatanga Hauora Māori from this site to find out more about application criteria and how your organisation might apply.

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PROSTABLOG NZ: Two top NZ prostate cancer experts were today appointed to a completely renewed Cancer Control Council, which gives expert advice to the Ministry of Health. READ MORE>

Lamb

Lamb - in

BrettDelahunt

Delahunt - in

Minister of Health Tony Ryall has appointed a new 11-person council, including:

  • Professor Brett Delahunt (right) Wellington School of Medicine and Health Sciences – Department of  Pathology and Molecular Medicine,
  • and Professor David Lamb, (left) brachtherapy expert and Otago University Medical School prostate cancer researcher.
tizard

Tizard - out

atkinson

Atkinson - stays as chair

They give direct prostate cancer voices to the council, whose membership has been totally replaced apart from Otago Medical School’s Associate Professor Chris Atkinson (right)

He will take over chairing the body from former Governor-General Dame Cath Tizard (left).

“One of the Government’s six health targets is improved waiting times for cancer services,” says Mr Ryall.

“The Council’s membership has a strong clinical leadership, and this will ensure expert advice to improve District Health Board performance.”  READ MORE>

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PROSTABLOG NZ: The NZ government needs to add prostate cancer to its health priorities, if a Prostablog poll is any indication.

That was the most popular choice of those voting in the poll, which asked Kiwis what they think the Health Select Committee inquiry into prostate cancer should hear.

The closing date for submissions to the inquiry was today.

Votes in the Prostablog poll numbered only 48, which seems a modest result – until you compare it with a similar poll run recently on America’s most prominent prostate cancer website, the New Prostate Cancer Infolink.

It got only 120 votes, so considering the population difference, we didn’t do too badly.

Notwithstanding the extent of the vote, the Prostablog poll has a clear message for the government:

  • Add prostate cancer to the health priorities (it doesn’t get a mention in the new list announced in May.
  • More money should be committed to prostate cancer research (does anyone know how much is spent now?).
  • It should be compulsory for all GPs to offer prostate cancer tests.
  • Population-based prostate cancer screening is urgently needed.
  • The Ministry of Health should be running a TV campaign like those used to spread the screening message to women about breast and cervical cancer.
  • NZ needs more modern prostate cancer treatment drugs.

The Prostablog poll

What should the prostate community tell the NZ Parliamentary inquiry into prostate cancer?

POLL

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ABC BRISBANE: It seems Australian men still aren’t getting the message about prostate health -  so a new, federally funded programme is relying on volunteer ‘health ambassadors’ to urge men in their local communities to make regular visits to their GPs. READ MORE>

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TonyMAINPROSTABLOG NZ: The NZ parliamentary inquiry into prostate cancer closes off its submissions this Friday…and to mark the occasion, I want to write about a man called Tony.

He’s a mid-50s Kiwi bloke. Friendly, articulate, life-experienced, a bit more adventurous, perhaps, than some.

He and wife Marlene (at right) run an excellent bed and breakfast in Mt Eden, Auckland, under the shadow, almost, of where $300 million of my money is being spent revamping Eden Park for the rugby world cup in 2011.

Tony drove trucks across America for a while, until the mid-2000s. Marlene missed him, so joined up, taking the wheel during daylight. They had a fantastic time.

TonyMAIN2But now they’re back home, with Tony working three jobs as they build up the B & B (left) during the recession.

He runs a disability transport service with his vans, walks people around central Auckland city at night telling them ghost and murder stories, and helps Marlene with the homestay.

By all odds, Tony has a 50% chance of hosting a cancer in his prostate.

He doesn’t know it yet, either way. He hasn’t been checked. He’s been too bloody busy.

But now he’s going to the doc and he’ll endure the finger up his backside and the scratch in his arm.

Why? Because Lin and I stayed with Tony and Marlene last weeked and he got an earful from me about getting checked.

Why am I telling you this?  Because Tony is fairly typical of most of the Kiwi men I know (the ones who haven’t had prostate cancer). They either don’t get tested, get only the PSA, or were tested “once” and think it’ll be fine for a few years.

They are what the Health Select Committee inquiry into prostate cancer screening and testing is about.

Two bitterly opposed protagonists

Anyone who thought NZ’s recent prominent murder trials (Bain, Weatherston, et al) were problematic for their juries, spare a thought for the Health Select Committee.

Not only must it contend with the politics of health care, it also faces two ferociously opposed lobby groups that can each present a compelling case.

On one side will be the NZ prostate community, comprising prostate cancer patients, survivors, some of their medics (GPs, urologists, urology nurses, oncologists, etc), and a vociferous band of patient advocates, the 330-strong Prostate Cancer Foundation.

On the other is the health care bureaucracy, encompassing a heavyweight team of health professionals, managers, advisers, epidemiologists, academics, researchers and various subgroups that include some GPs…and the NZ Cancer Society.

Both will lobby the inquiry with statistics, research, study results, precedents, and on one side, at least, some emotionally gruelling anecdotal evidence.

What will each side say?

The bureaucrats (the Ministry of Health and its pilot fish advisory committees) will say what it has always said: we should not adopt a screening and testing programme like that offered to women for breast and cervical cancer because it will do more harm than good.

Their argument is strong, and is the same one argued by other governments’ medical agencies.

It is this: many men (maybe 50%) will get prostate cancer in their lifetime, but only a few (12% to 16%) will contract a form that has the potential to kill them – and there is, as yet, no way to know (before treatment) which kind a man has got.

They say if there is outright encouragement for all men to be tested, whether they have symptoms or not (most won’t, initially), it will lead to unnecessary treatment.

This would cost the government a lot more as well, some argue, but that’s not a point the bureaucracy will highlight, since it doesn’t sound very humane.

Meantime, leave it to patients to raise such matters with their GPs, then make their own decisions based on facts they glean from consultation and research (ie, Dr Google).

The bureaucrats will say there is good reason to trust GPs to do the right thing.

A survey of nearly 350 general practitioners published in 2003 (GP survey 2003) found 74% would PSA test a 55-year-old man who asked (or presented for an annual check-up), with that number rising to 93% if the man’s family history included prostate or breast cancer.

The prostate community argues that since PSA blood tests became widely available in the 80s there has been significant decline in the number of deaths from prostate cancer, and this could be accelerated if screening and testing were promoted to the whole male population.

They say leaving it up to men to raise prostate testing with their doctors is not good enough.

Some men don’t go to the doctor unless they have to, which is a particular problem with prostate cancer, a devious disease that often shows its face when it’s too late for treatment.

Non-consultation is a factor that may apply particularly to Maori and Pacific Island men: the former have twice the death rate of non-Maori. No statistics are available for PI men, it seems.

The prostate community is concerned that some GPs are confused about their role in the prostate process.

Some refuse to test, some don’t proffer advice unless the patient speaks up first, some offer PSA only, some offer both PSA and digital exam. Some men die as a direct result of such a hit-or-miss system, the PCF says.

The foundation and its medical advisers know many cases of men who discover prostate cancer too late.

These are tragic stories, exemplified by the account being written on this website by Mary about her struggle with the medical profession to get treatment for her husband, John. It’s a heart-breaking tale.

There is some bitterness in this debate.

The prostate community is seen as deeply swayed by the emotional influences of suffering the disease or benefiting from dispensing treatment; the bureaucracy is considered heartless, unduly influenced by statistics, gender-biased, and penny-pinching.

Both sides are gathering their forces as this is written.

The Ministry’s line, probably, is encapsulated in advice it received from its satellite National Screening Advisory Committee this winter, after the committee examined the results of the two large overseas screening studies reported in March.

It recommended the Director General of Health should note that:

a) the benefits of PSA screening for prostate cancer identified in the European trial were small;

b) no benefit of prostate cancer screening was identified in the US trial;

c) both trials identified considerable screening harms related to over-diagnosis and over-treatment;

d) the benefits of PSA screening identified in the European trial were observed using an average screening interval of four years, whereas a screening interval of one to two years is more commonly used in general practice;

e) the utility of prostate screening increases with age;

f) a longer study follow-up period may alter trial results; and

g) a watching brief of these two prostate cancer screening trials should be kept, including similar trials of prostate cancer treatment effectiveness, to inform men about making prostate screening decisions.

There is some inevitability, then, about how this inquiry will proceed.

The Ministry hasn’t changed its stance, and the PCF has grown all the more powerful since it gathered considerable funding from the Movember crusade in 2007.

Which suggests the outcome will be influenced by political expediency. As these things usually are.

It’s not a good time to be appealing to a government that’s busy slashing spending in all sectors.

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