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Posts Tagged ‘prostate cancer screening’

PROSTABLOG NZ: Exact meaning of the word “encourage” will be pivotal  in the continuing New Zealand saga on how best to prevent prostate cancer.

“We will be encouraging men to go to their GPs to discuss optionsincluding whether or not they should have a PSA test,” says the chairman of Parliament’s inquiry into prostate cancer, Paul Hutchison, in today’s Dominion Post newspaper (see below).

In the same story, his statement is welcomed by Prostate Cancer Foundation of NZ president Mark von Dadelszen: “…we would certainly applaud that move.”

What they both mean by the term “encourage” is about to become the focus of a debate that has churned around in global prostate cancer politics since PSA testing became commonly available in the early 1990s.

First question: how does “encouraging” men to be tested differ from a national screening programme (which Hutchison signals will be rejected in the inquiry report due in a matter of weeks)?

A national screening programme presumably involves the Ministry of Health spending millions promoting tests to the general populace, as it does with breast and cervical cancers.

Such programmes “encourage” people to get along to their doctor and have the tests.

How will men be encouraged? Not with a lot of advertising, it seems.

So how, exactly?

By training barbers to spread the word to their clients, as has been tried in the US?

By sending doctors into communities to talk about risks and options, as the Foundation did last year when it flew a team to the Chathams?

By leaving it to the Foundation to publicise the disease and urge men to act, as happens now?

Whatever approach the Health Select Committee is about to recommend, it needs to deal with a mammoth in the waiting rooms – the Ministry of Health instruction to GPs that they must not raise the topic of PSA and rectal examination until the patient does or unless they spot symptoms obviously related to what is often a symptomless disease.

This is the real crux of the dilemma the Select Committee has presumably been wrangling with since its first public hearings in September, 2009.

What instruction will it recommend the Government give to the Ministry, whose staff and advisers  adamantly oppose any widening of the availability of PSA testing?

Up to now, men have been the subject of a mild but just as deadly form of Russian roulette when it comes to being diagnosed.

Take my own case.

Over the past 30 years, I’ve been under the care of four GPs. The first never mentioned prostate cancer (to be fair, I was under 50); the second (mid 1990s) refused to consider PSA tests because to him they were unproven; the third insisted on it without my bidding; and my current one responded readily to my request for tests (saying Ministry instructions forbade him raising the matter unless I spoke up first!).

Anecdotal evidence suggests the Ministry’s obfuscation is becoming increasingly irrelevant – for some people, anyway.

The Foundation’s awareness campaigns have been effective, if I judge by the number of male acquaintances now being diagnosed early and successfully treated.

However, I suspect there are dangerous class factors at play here.

Me and my mates are okay because we have been blessed by education, higher socio-economic status, media awareness and access to health provision.

I fear for those who don’t. The Ministry’s stubbornness condemns them to an uncertain fate.

National prostate screening rejected

Dominion Post April 2, 2011

A PARLIAMENTARY inquiry into prostate cancer screening will not be recommending a national screening programme despite pressure from cancer survivors to do so.

The Prostate Cancer Foundation has backed the committee’s approach, but a former patient says the decision is disappointing.

Health select committee chairman Paul Hutchison said the inquiry, which has been running since May 2009, was not due to report back for another few weeks, but when it did, it would not advocate screening.

There was still controversy over whether blood tests for prostate-specific antigens led to fewer prostate cancer deaths, he said.

Heightened levels of prostate specific antigen – PSA – can indicate the presence of prostate cancer. However, early detection can result in aggressive and unpleasant treatment of tumours that would never have grown or created ill-health.

The inquiry has heard from a huge number of prostate cancer survivors, many of whom asked for a screening programme for all men aged 50 and older.

Dr Hutchison could not go into detail about the committee’s findings but said there were two main conclusions.

‘‘We will not be recommending a PSA screening programme. However, we will be encouraging men to go to their GPs to discuss options … including whether or not they should have a PSA test.

‘‘Those are the two points that are loud and clear.’’

Prostate Cancer Foundation president Mark von Dadelszen said the organisation did not support a national screening programme because of ‘‘issues’’ with the PSA test.

‘What it does advocate is that men should be encouraged to have screening tests . . . we would certainly applaud that move.’’

Napier farmer Duncan McLean, who has just got the all-clear five years after being diagnosed with prostate cancer, said encouragement was good but the committee should recommend a full screening programme.

Mr McLean, 57, had his prostate gland removed in 2006 after several years of increasingly high PSA readings, followed by a biopsy that confirmed the cancer.

‘‘PSA testing is essential. I’m alive today because of it. It’s really disappointing they’re not [recommending screening].’’

Fears about over-treatment were ‘‘bollocks’’, he said. ‘‘You don’t leap in and go under the surgeon’s knife – I was monitored for three years before I had surgery.’’

International research on the matter is split, with several largescale studies under way.

The results of a 20-year Swedish study, published yesterday in the British Medical Journal, found screening did not significantly reduce prostate cancer deaths but the risk of overdetection and unnecessary treatment was considerable.

However, another Swedish study found death from prostate cancer more than halved among men who were screened.

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REUTERS: British scientists say they have developed a lab test that can accurately distinguish prostate cancer from healthy tissue and other prostate conditions. READ MORE>

Researchers at a genetics and diagnostics firm Oxford Gene Technology say the set of biological signals, or biomarkers, they have identified was able to distinguish healthy tissue and benign prostate disease from prostate cancer with 90 percent accuracy in initial laboratory sample tests.

A full test for use in doctors’ clinics is likely to be at least five years off, they said, but their pilot study testing around 130 samples showed encouraging results in a disease area where more accurate diagnostic tests are sorely needed.

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NEW PROSTATE CANCER INFOLINK: It has been well understood for some time that there is confusion among men in general and among members of the primary care community about appropriate use of PSA testing. READ MORE>

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NEW PROSTATE CANCER INFOLINK: The debate about mass screening for prostate cancer has been moved on significantly by by some recent Swedish studies, writes Mike Scott:

Is there a simple take-away from these three Swedish studies that correlates to the data from the meta-analysis of the six major screening trials? We believe that there is, and it is based on a testable premise:

  • All men should get a PSA test every 5 years starting at age 40, each of which is likely to be able to project a 25-year risk for diagnosis of prostate cancer and/or clinically significant prostate cancer.
  • Men who are shown to be at no significant 25-year risk based on these 5-yearly PSA tests may not need to get interim PSA tests unless there are other reasons for them to do so (based on clinical signs and symptoms, ethnicity, genetics, and other known factors).
  • Men who are shown to be at significant 25-year risk based on any one of the 5-yearly PSA tests should be encouraged to monitor their PSA with care over time in consultation with a prostate cancer specialist and make appropriate clinical decisions based on their individual data.

READ MORE>

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ASSOCIATED PRESS: Screening for prostate cancer will not be included in President Obama’s new preventive health insurance next year. READ MORE>

New health insurance policies beginning on or after September 23 must cover — without charge — preventive care that’s backed up by the best scientific evidence. Most people will see this benefit, part of the Obama administration’s health care overhaul, starting January 1.

The list includes tests strongly recommended by the US Preventive Services Task Force, an independent advisory panel that evaluates research.

Of note for men: Screening for prostate cancer isn’t included on the list because its benefits haven’t been conclusively shown by the best research, at least to the high level required by the law.

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PROSTABLOG NZ:  HERE are four key issues the NZ Parliamentary inquiry into the detection and treatment of prostate cancer ought now to be focusing on:

  • Mass screening…or not: Not. The evidence in favour of mass screening of all middle-aged men for prostate cancer is not sufficiently strong in statistical terms to overcome the counter-arguments concerning needless and over-treatment and high likelihood of after effects that will blight quality of life.

But…it’s not strong enough yet. That may change as more studies are done and closer analysis of the large random trials is completed. PSA testing may also improve, or be replaced with something better, a test that defines the actual risk to the patient.

  • Guidelines to GPs must be revised. Currently, GPs are forbidden by the Ministry of Health to routinely offer PSA tests and/or rectal examinations for prostate cancer unless a man asks, or mentions symptoms. Since this can be a symptomless disease (until it’s too late), that is unacceptable. It also presumes that people don’t move around, change doctors, lose track of medical records, or simply have little idea of the implications of dad dying of prostate cancer.

If the Ministry of Health wants to avoid high-risk treatment being offered unnecessarily, it needs to move the initial gatekeeping further up the food chain to the specialists.

  • Specialists’ advice needs to be delivered via a more balanced and less costly method. At present, the system works well enough up to the point the pathologist finds signs of cancer in biopsy samples.

But after that, men are left to fend for themselves when it comes to seeking advice from a range of authorities. Some don’t bother, and just go with what the urologist offers. Some can’t afford the $1600 charged by a cancer specialist (oncologist), who may be the most neutral source of advice available.

In the US, the first specialists in the hierarchy, urologists, earned themselves the unenviable moniker of “prostate snatchers” because of the lucrative, medical insurance-backed business of prostate surgery.

How about panels of doctors representing the main treatment options in NZ (surgery, robotic surgery, external beam radiation, brachytherapy, watchful waiting) reviewing the case notes and offering clearly explained options to patients?

  • The public needs to be kept up to date – in layman’s terms – with diagnostic and treatment developments. This is not happening at present. The Ministry and its satellite committees do not have readily available, up-to-date information on the web to help men with newly diagnosed prostate cancer become fully informed before making one of the biggest decisions of their lives.

As wealthy male baby boomers hit the danger zone, enormous amounts of US, European and Asian money are going into researching and developing new drugs, methods of surgery and radiation, diagnostic tools and a bewildering range of related methdologies.

That’s the point – it’s bewildering to the average Kiwi, who must hope his medics are keeping up to date and that the government is adequately funding new treatments.

For example, there is Provenge, a new $100,000+ drug regime that will extend life for a few months, and which is now selling big in the US. When will we see it here?

Communicating the relevance of the overseas prostate industry boom to Kiwis cannot be left solely to the news media here: that’s worse than leaving it to chance and the public relations industry.

Few, if any, journalists in NZ take an abiding interest in prostate cancer (why would they – it’s one of many diseases), and what they do write is sometimes ill-informed, incomplete, inaccurate and out of date.

Finally, the Health Select Committee would be wise to keep its files open on this inquiry. It would be a mistake to shut the doors on a tsunami of prostate cancer information that emerges daily on the web.

Developments are moving so quickly, the committee should require the Ministry of Health to report regularly about what’s happening. The inquiry report, when it finally emerges, should be an interim one that can be updated over time.

The committee is wrestling with questions that are far from settled.

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NZ DOCTOR: Harbour Health PHO told the NZ Health Select Committee yesterday [15 September] it is just weeks away from testing an electronic decision-support tool, which describes a care pathway for the assessment and management of prostate health. READ MORE>

Men and their GPs are often confused by the conflicting messages about prostate cancer, Dr Lannes Johnson (Harbour Health PHO medical director) told the committee.

“On one hand we tell GPs not to screen for prostate cancer; on the other, we say, every man has the right to testing and advice.

“The controversy has not been resolved by the evidence-based medicine approach…But sensible decisions can be made in primary care even without consensus between urologists, oncologists or epidemiologists.

“We really cannot leave things as they are.”

PROSTABLOG NZ:  Decision aids to assist men make choices about prostate cancer treatment have been around a while, but have only recently been adapted for use via the internet.

The Australians announced in July good results with one designed for men with prostate cancer in their families. READ MORE>

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PROSTABLOG NZ: The debate within medical circles about the benefits – or not – of mass screening for prostate cancer just got a little more foggy in NZ.

Parliament’s Health Select Committee inquiry into prostate cancer was due today to hear from Lannes Johnson, medical director for the Harbour Health PHO, who – if a report in last week’s NZ Doctor magazine/website is to be believed – would enthuse about the results of a “new” study just released from Sweden.

Prostablog reported (also somewhat breathlessly) on the Göteborg study back in July after it appeared in Lancet Oncology, pointing to commentary by Mike Scott at the New Prostate Cancer Infolink.

Despite the positive tone of the NZ Doctor article – the majority of whose sources depicted the study as proof that population-based screening is fully justified – Scott’s analysis does not support that.

And neither does an editorial (represented by one paragraph in the NZ Doctor article) by Cambridge University’s Prof David Neal, which appeared at the time of the Lancet Oncology report.

After rehearsing the contents of the Goteborg study, Scott had this to say:

  • This study appears to show clearly that, in a screening-naïve population of men aged between 50 and 70 years of age, biannual PSA testing can lower the risk for prostate cancer-specific mortality by at least 40 percent.
  • In addition, the study shows that the proportion of patients diagnosed with prostate cancer and requiring hormone therapy in the screening group (103/1,138 or 9.1 percent) was much less than half that of the patients in the control group (182/718 or 25.3 percent), implying that early detection also reduced the risk for metastatic disease.
  • However … the study also shows clearly that (at 14 years of follow-up) biannual PSA screening has no impact whatsoever on the overall mortality rate in the same population.

We are therefore potentially faced with the difficult question of whether mass, population-based screening that does affect disease-specific mortality but does not affect overall mortality is justifiable based on the costs, the effort, and the potential harms to the men who are over-treated.

The single most important fact about this study, as far as The “New” Prostate Cancer InfoLink is concerned, is that it finally has provided us with a highly structured, ongoing assessment of the potential value of mass, population-based screening for prostate cancer in a previously screening-naïve population.

The study also includes full treatment information on all men diagnosed with prostate cancer over the course of the study.

This means that at last we have a real baseline against which to assess the data from all other screening studies, and we can use this baseline to recognize the inherent problems of the PLCO and ERSPC studies, which include short follow-up (to date) in both studies, variation in protocols (within the ERSPC cohorts), and data adulteration resulting from PSA testing among the “unscreened” patient cohort (in the PLCO study).

The data from the Göteborg study may still not provide a convincing rationale for mass, population-based screening based on use of the PSA test, but it certainly does set the standard for what must be expected from any new test that may come along and show promise as a true screening test for prostate cancer in the future.

The one regrettable fact about this study is that if it had included just one additional age cohort (of men born between 1945 and 1950), we might have been able to gain real insight over time into the benefits of even earlier detection for a period of up to 30 years.

A much more cautious note here, then, than these comments in NZ Doctor:

“The Government can hardly say they won’t screen for prostate cancer if the science supports it,” Dr Johnson says, referring to an ongoing Parliamentary inquiry into the early detection and treatment of prostate cancer.

Auckland urologist Robin Smart says the bottom line for him is that the study shows prostate cancer screening could prevent 300 of the 600 deaths from prostate cancer that occur every year in New Zealand. “All of the results strongly suggest that PSA screening is a really good idea,” Dr Smart says.

NZ Doctor concluded:

The results of the Göteborg trial are due to be presented to the Health Select Committee next week (today, September 15) as part of its inquiry into prostate cancer. Dr Johnson will talk about the results during a presentation by Harbour Health on PHO capability for reducing the burden of cardiovascular disease, smoking and diabetes.

Let’s hope the committee takes the time to read more widely about the study.

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PROSTABLOG NZ: It’s almost a year since the first hearings were held by the NZ Parliament’s Health Select Committee inquiry into the early detection and treatment of prostate cancer.

The obvious question now is when will it report back.

Since it published its terms of reference in August last year, the committee has received 33 submissions, four of them from the influential health lobby group, the NZ Guidelines Group, whose last submission was made in December.

This document made it clear that the group – an independent incorporated society originally set up by the government in 1996 – is opposed to population-based PSA screening.

To save one life, up to 41 men could incur significant harm.

It bases this view on its assessment of numerous NZ and international studies, including two large randomised trials (one European, the other American) that were reported last year.

Here are some of the last pages of the group’s December, 2009, submission (RCT = random controlled trial):

This also appears to be the main thrust of submissions on PSA testing from other health authorities (although the Guidelines Group is at pains to stress it is independent from the Ministry of Health).

Another “official” organisation, the National Health Committee, said in its submission (August 26, 2009) that it has seen nothing to change its 2005 advice to the MOH that population-based PSA screening is not an acceptable option.

However, it did favour targeted screening of high-risk groups, such as men with a family history of prostate cancer.

The NHC is aware that since providing its advice in 2005, clinical practice has found
that targeted screening for men at high risk of prostate cancer appears to be useful
and potentially cost effective. These are men who have a family history of prostate
or related cancers.

The Royal NZ College of General Practitioners – presumably speaking on behalf of doctors on the frontline – said in its submission it would go along with the NZ Guidelines Group’s views.

It did make a couple of pleas, however, calling for up-to-date information to hand out to patients, and for treatment to be available to all:

It is important that inequities in access relating to follow up after positive
screening results, and for symptomatic men, are identified and eliminated.

The Cancer Society agreed with the Guidelines Group, and backed this up by quoting from selected organisations in other Western countries.

Most agencies around the world have some form of recommendation that decisions for screening for prostate cancer should be made on an individual basis and in consultation with a medical professional:

The Australian Cancer Council states that:
“In the absence of direct evidence showing a clear benefit of population based screening for prostate cancer, a patient centred approach for individual decisions about testing is recommended. Screening discussions and decisions should always include and take into account, age and other individual risk
factors such as a family history of the disease” (Cancer Council Au 2005).

The American Cancer Society states that:
“The American Cancer Society (ACS) does not recommend routine testing for prostate cancer at this time. ACS believes that doctors should discuss the pros and cons of testing with men so each man can decide if testing is right for him. If a man chooses to be tested, the tests should include a PSA blood test and
DRE (digital rectal exam) yearly, beginning at age 50, for men at average risk who can be expected to live at least 10 more years.” (American Cancer Society 2009).

The UK Cancer Research Council states:
“in the UK, there is no national screening programme for prostate cancer because trials have not yet shown clear evidence that screening will reduce deaths from this disease. Also, many men diagnosed with
prostate cancer have very slowly growing cancers that will never cause any symptoms or problems in their lifetime. So at the moment there is no clear benefit in diagnosing prostate cancer early and it may actually cause harm for some men.”(Cancer Research UK 2009).

Urological Society of Australia and New Zealand states:
“Individual men aged 50 to 70 years with at least a 10 year life expectancy should be able to be screened by annual DRE and PSA testing, after appropriate counselling regarding the potential risks and benefits of investigations and the controversies of treatment.”(Urological Society ANZ 1999).

The majority of submissions – from prominent medical practitioners, prostate cancer lobby groups and patients – urged the committee to recommend PSA testing, if not on a population (all men) screening basis, then at least as a service offered routinely by GPs, without men having to ask (the current MOH policy).

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PROSTABLOG NZ:  This hardly helps those of us who support the need for widespread prostate cancer screening, but deeper analysis of the European randomised study of PSA testing says such screening is dangerously counter-productive.

Dangerous in the sense that – as the epidemiologists (trends counters) have long claimed – too many men with harmless prostate cancer are being treated aggressively, and needlessly.

The new analysis comes form a bunch of Dutch scientists, who conclude that population-based (that is everyone) screening using the PSA test, while undoubtedly saving some lives, cannot be justified because of the potential over-treatment harm that may be done to 60%-plus of men diagnosed with the cancer.

Mike Scott at the New Prostate Cancer Infolink reaches the same conclusion, and says we need to rethink the whole approach to prostate cancer diagnosis. READ MORE>

More than ever, we must find a way to separate those with life-threatening versions of prostate cancer from those whose disease will not kill them.

It seems, in a way, that we are no further ahead than prior to the days of the PSA test’s introduction in the 90s.

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