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Archive for the ‘Govt prostate policy’ Category

new-zealand-parliamentJULY 20: PROSTABLOG NZ: New Zealanders have until August 21 to make submissions to the world’s only current parliamentary inquiry into prostate cancer screening.

Terms of reference for the inquiry by the Health Select Committee were announced today. The committee seeks:

1.      A summary of the contemporary literature on the subject including, incidence, mortality, groups at risk, testing options (with particular reference to age and family history, treatment and what other countries are doing).

2.    Opinions from –

  • affected and asymptomatic men, their families, patient advocacy groups including the Prostate Cancer Foundation and the National Screening Advisory Committee;
  • specialist clinicians, radiation oncologists, urologists and general practitioners;
  • epidemiologists, and those involved with the Ministry of Health, New Zealand Guidelines Group.

3.    Best methods to promote awareness for early detection and treatment of prostate cancer.

4.    A cost benefit analysis, if appropriate.

READ MORE>

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JULY 3: PROSTABLOG NZ: In what seems to be exquisite timing, NZ’s parliamentary select committee on health is starting an inquiry into prostate cancer screening – just as some of the best recent analysis of screening emerges in the US.

The latest informative discussion comes from Mike Scott at the New Prostate Cancer Infolink website, one of the leading American aggregators of up-to-date information.

As global debate hots up following recent publication in a medical journal called CA: A Cancer Journal for Clinicians of an article about screening and an accompanying editorial, Scott today makes some interesting points:

  • Media reporting of this latest look at the two large randomised studies is well wide of the mark.
  • What the article actually makes clear is we just do not know how best to use the tools currently available to test an individual man so as to ascertain with accuracy his real risk for clinically significant prostate cancer.
  • So — surprise, surprise — we need better tests, as America’s Prostate Cancer Organizations have already clearly stated.
  • A critical element, covered in the article, is the importance of taking account of the patient’s age, life expectancy, family history, race/ethnicity, and other personal health factors in making the decision whether testing for prostate cancer is appropriate or not.
  • The article does not discuss, at all, the potential merits of  “baseline” PSA testing (at any specific age).
  • The journal’s accompanying editorial uses some “loaded” language in making the correct recommendation that regular, mass, population-based screening is not currently justified based on the available evidence. That “loaded” language is centered around the use of the terms “over-diagnosis” and “over-treatment.”
  • There is excellent evidence today that “mass, population-based screening” using mammograms to look for breast cancer is no more justified that prostate cancer screening, on any good statistical basis. Some 2,970 women must be screened once to find 27 cancers and save one life (in women aged between 40 and 65 years of age). The editorial repeats the finding of the European trial that it would be necessary to screen 1,410 men and find an additional 48 cancers to prevent one prostate cancer-specific death.
  • There are simple answers to the issue of “over-reaction” (to screening findings from doctors and patients), and they start with greater honesty — among the clinical community and among the survivor community — about what we really do and don’t know.
  • Over the past 30 years, prostate cancer deaths have dropped 20% in the US, but…”We still can’t tell [which patients are at real risk] beforehand, and so fear and  ‘standard practice’  tell us that we should proceed with treatment ‘to be on the safe side’. We need to do better. And it doesn’t help to demonize the problem with terms like ‘over-diagnosis’ and ‘over-treatment’.”
  • In all truth, we do not have good enough information to allow us to know the best thing to do for the vast majority of men who are at only a statistical (as opposed to a clinically evident) risk for prostate cancer.

It’s to be hoped someone draws the Health Select Committee‘s attention to this latest development in the debate, which has rumbled along since late March, when the results of the long-awaited studies were published in the New England Journal of Medicine – and failed to resolve anything.

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JULY 2:   JACKSONVILLE NEWS.COM:  Sound familiar? The Obama government wants to trim the nation’s annual $US2.4 trillion health bill, so an Institute of Medicine committee has released a list of 100 priorities it recommends for “comparative effectiveness” research. READ MORE>

Localised prostate cancer treatment, which can range from “active surveillance” to zapping the cancerous cells with proton radiation, was among 25 priorities that, the committee said, should be studied first.

Congress ordered the list as part of a $1.1 billion effort to compare the effectiveness of drugs, medical devices and treatments. READ MORE>

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BarryYoungJUNE 22: PROSTABLOG NZ: For many years New Zealand men have refused to accept the lack of a formal screening programme for prostate cancer and have opted for self-requested screening, says NZ Prostate Cancer Foundation president Barry Young (right).

“Without screening programmes, New Zealand men have taken the initiative and established their own,” he says in a statement released to Prostablog NZ. today.

“Nearly 3000 men are diagnosed with prostate cancer every year and about 600 die of it, so you can see the scale of what is happening.

“We are hopeful that the recently announced Health Select Committee inquiry will decide to change this and create a formal prostate cancer screening programme.

“It is every man’s right to know what is happening within his body and to decide for himself whether he should be treated for a disease or not.

“This is particularly the case with prostate cancer, which can be developing within a man’s body without him knowing about it.

“What men have to realise is that in its early stages prostate cancer doesn’t usually exhibit symptoms and when symptoms do occur it is usually too late for effective curative treatment.

“This is why men need to be screened for the disease.  The best chance to cure it is while it is still within the prostate.  Once it is out of the prostate it is usually too late.

“About 10 per cent of men will get prostate cancer and this is bad enough for the average bloke.  But there are some walking time bombs out there, men who have a father or grandfather or brother who has been diagnosed with prostate cancer.

“These men are many times more likely to get the disease.  Depending upon how many of their direct relatives have been diagnosed with prostate cancer, the likelihood that they will get it can climb up beyond 80 per cent.

“Because of this we recommend that men begin annual screening for prostate cancer when they reach 50.  If there is a history of the disease in the family then the screening should start at 40.

Paul Hutchison“We trust that this is the sort of thing that will be looked at during the Health Select Committee inquiry into screening for prostate cancer.  We have already offered the chair of the committee, Dr Paul Hutchison (left), our complete co-operation.”

Mr Young says the decision about whether to be screened for prostate cancer, and then whether to be treated for it, is a matter for each man and his family.

Men should be informed about the various pros and cons associated with the diagnosis and treatment of prostate cancer.

“It is a complicated business and we find that men and their families often need guidance in making a decision, but in the end the decision must be theirs, once they have been fully and accurately informed.

“The Foundation’s mission statement says our role is: ‘to create or enhance an environment to empower men to make informed decisions about the diagnosis and treatment for prostate cancer’.

“I don’t see how anyone can argue with that, and if a screening programme helps with this then we will be all for it.”

For any further information, please call Barry Young, 0274-825-253

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PROSTATE INQUIRY: What’s caused NZ government to revisit prostate screening issue?

JUNE 21: PROSTABLOG NZ: While the hopes of those pushing for prostate cancer screening were buoyed by last week’s NZ Government announcement of a select committee inquiry, the chances anything will change are uncertain.

Politicians, even those with medical backgrounds, must rely heavily on the advice of experts when it comes to health policymaking, and any signs the experts are about to change their views on this complex issue are not encouraging.

Medical people with an interest in prostate cancer have been waiting for most of this century to hear the results of a couple of massive, long-term, random studies on PSA testing and screening, which were expected to prove one way or another whether population-based screening is the right thing to do.

Mention of the trials, in the US and Europe, peppers the research papers of medical academics, especially those most opposed to screening all men, the epidemiologists.

The trial results are now in (published in the New England Journalism of Medicine in March) and those looking for irrefutable evidence either way will have been disappointed. The Australian Prostate Cancer Foundation went so far as to say the trials were flawed and the results suspect.

NZ’s Ministry of Health has been keeping an eye on all this, it says, and one of its committees met last month to discuss these and other recent findings.

The MOH promised a statement after this process, but has kept quiet, and instead the prostate community on June 18 got news of the new parliamentary inquiry.

The announcement, incidentally, came more than a month after the Health Select Committee actually made its inquiry decision, which on Parliament’s official website is dated May 27.Select committee

So what’s happened?

It seems a confluence of the following has produced the right conditions for something to happen, a perfect storm:

•    a new government, Minister of Health, and Health Select Committee;
•    a five-year gap back to the last official review of NZ’s prostate screening policy;
•    the release of the randomised studies’ results;
•    and with that, an upsurge in world-wide debate;
•    the Prostate Cancer Foundation of NZ’s quiet and consistent lobbying in favour of some sort of screening;
•    continuing horrific statistics for Maori men, who die of prostate cancer at twice the rate of non-Maori;
•    and high current interest in prostate cancer from researchers and drug companies, especially in the US.

The political aspect of this development is the most under-reported (NZ media coverage of prostate cancer tends to be sporadic and superficial) and therefore potentially the most interesting.

The Health Select Committee last examined prostate screening in 2006.

The then-committee – comprising MPs Sue Kedgley (chairperson), Maryan Street (deputy chairperson), Dr Jackie Blue, Dr Jonathan Coleman, Jo Goodhew, Ann Hartley, Sue Moroney, Hon Tony Ryall (now Minister of Health), Lesley Soper, Barbara Stewart and Tariana Turia – considered a 2005 petition from ACT MP Muriel Newman (signed by 585 others) calling for a change in screening policy.

After hearing Ministry of Health advice, the committee rejected Newman’s call for population-based screening, but recommended the government develop up-to-date guidelines to assist GPs and their patients make decisions about testing and treatment. The MOH produced these in 2007.

In its report, the committee also said:  “We recommend that the Government evaluate the evidence of the two trials that are presently being conducted into whether screening can reduce the incidence of death from prostate cancer, and re-assess its policies as soon as they are completed.”

In opposition over the past decade, National MPs and one of their natural allies, ACT, have been vociferous in questioning what they saw as lack of action by the Labour-led government.

Many of these parliamentarians – Muriel Newman and NZ First list MP Barbara Stewart notable among them – are now out of Parliament, but two remain who have voiced their concerns in Parliament about prostate cancer.

One is chairman of the new Health Select Committee, former clinician Dr Paul Hutchison, who featured in the House on September 14, 2004, when he pushed then Labour Minister of Health Annette King to concede the Government wasn’t doing enough about prostate cancer.

She conceded nothing, and stuck with her MOH advice.

Here’s how Hansard recorded the exchange:

September 14, 2004: Dr Paul Hutchison to the Minister of Health: Does the Ministry of Health have a view on the value of initiating a ‘prostate awareness’ campaign; if not why not?

Hon Annette King (Minister of Health): Yes. The Ministry supports the views of the National Health Committee which does not recommend prostate screening for asymptomatic men because of its lack of proven benefit and the potential for harm arising from unnecessary radiotherapy, surgery or other treatment at this stage, but we will continue to monitor international trends and research.

The committee has, however, published information regarding issues men need to consider when seeking prostate screening tests in the brochure Checking for Prostate Cancer, Information for men and their families. This brochure is available on the New Zealand Guidelines Group’s website: http://www.nzgg.org.nz.

Hutchison: Is she satisfied that the April 2004 report of the National Health Committee relating to prostate cancer screening provided up to date and best practice advice; if not why not?

King: Yes.

Hutchison: What specific public health programmes are available to alert men to health problems such as prostate cancer; if there are none, why not?

King: There are no specific health programmes to alert men to prostate cancer because routinely checking men without symptoms of prostate cancer is not recommended. However, I refer the member to written question No 13279 regarding the National Health Committee and New Zealand Guidelines Group’s brochure on this issue. For initiatives in other health programmes, I refer the member to written question No 13269 (2004).

Hutchison: What advice does the Health Ministry recommend to men, specifically to help prevent and achieve early detection of prostate cancer, and if not why not?

King: The Ministry of Health endorses the guidance produced by the National Health Committee, which states that men who have concerns should see their GP. These guidelines are available on the National Health Committee website (http://www.nhc.govt.nz/publications.html).

The second is National list MP Dr Blue (another former clinician), who questioned the government in 2006 and 2007.

Here’s how she is recorded in Hansard:

October 16, 2006: Dr Jackie Blue to the Minister of Health: Has any preliminary work been done by the Ministry of Health on the costing and logistics of a prostate cancer screening programme; if so what are the results of any preliminary work?

Hon Pete Hodgson (Minister of Health) replied: In April 2004 the National Health Committee (NHC) published its report to the Minister of Health on prostate screening in New Zealand. The report did not recommend population based screening for prostate cancer. No further work has been done by the Ministry of Health on the costing and logistics of an organised population based screening programme.

Blue: When did PSA or prostate specific antigen testing become available in New Zealand?

Hodgson: The Ministry of Health is not aware of the exact date the PSA test became available in New Zealand. However, statistics in the publication Cancer Trends and Projections indicate that the PSA test was being more widely used from the 1990s onwards.

Blue: How does New Zealand’s current prostate cancer screening guidelines compare to Australia, United Kingdom, United States, Canada and European countries?

Hodgson: New Zealand’s current policy on prostate cancer screening is the same as Australia, United Kingdom, United States, Canada and European countries, and aligns with the recommendations of the World Health Organization.

Blue: Have the interim results of the prostate cancer screening trials involving hundreds of thousands of men in Europe and the United States been made available to the Ministry of Health; if so, what are the preliminary results; if they are not available, when are they expected to be available?

Hodgson: The Ministry of Health is aware of two large randomised trials occurring in Europe and the United States. The first interim results of these studies are expected by the end of this year.

Blue: What resources does the Ministry of Health provide to general practitioners regarding prostate cancer screening; when were they last updated?

Hodgson: The Ministry of Health has published a pamphlet Screening for Prostate Cancer for health care practitioners, which is currently being updated. The pamphlet was produced by the New Zealand Guidelines Group in 2004 and is available on the Group’s website (www.nzgg.org.nz).

Blue: What are the current guidelines for prostate cancer screening; when were these last updated?

Hodgson: There are no New Zealand guidelines for prostate cancer.

February 27, 2007: Dr Jackie Blue: Can the Minister guarantee that updated breast cancer surgical guidelines will be forthcoming, or will it be like the long-awaited update of the prostate cancer guidelines on the Ministry of Health website, which were promised 16 months ago but still nothing has happened?

Hon PETE HODGSON: The guidelines are under development now.

How do others on the eight-member committee stand?

One, Green Party list MP Kevin Hague, has declared his opposition to the inquiry even before it’s begun. The deputy-chair, Ruth Dyson, has on occasion been a defender of Labour’s “no-screening” policy over the past three terms.

The views of the other four might become apparent in a thorough search of Hansard, but are not prominent.

What are those in favour of screening up against as they prepare their submissions for the committee’s hearings, whose terms of reference will be announced this coming Wednesday (June 23)?

One of the strongest opponents is Ann K Richardson, Associate Professor, Department of Public Health and General Practice, Christchurch School of Medicine and Health Sciences, University of Otago, whose 2005 paper for the NZ Medical Journal said the following:

“The results from autopsy studies and the Finasteride trial are a warning.

“If healthy men have PSA tests, some will be diagnosed with prostate cancer that they would otherwise never have known about, and that would never have threatened their lives. This would be bad enough, but many men who are diagnosed with prostate cancer are offered treatment such as radiotherapy or surgery, and these treatments have significant side effects. The potential side effects include impotence, incontinence, diarrhoea, and death.

“Some of the men who suffer these side effects would never have known they had prostate cancer in the absence of screening, so they will have been directly harmed as a consequence of being screened.

“Although it is possible to understand and perhaps explain opposing views on prostate cancer screening, examining the risks and benefits shows that prostate cancer screening is not justified at present.

“Whether there is any benefit from prostate cancer screening is unknown. It is inappropriate to support screening in the hope that it will be found to be beneficial, since this would be gambling with men’s health.

“Prostate cancer screening fails to meet criteria for screening, and carries potentially serious risks. In the absence of conclusive evidence of benefit, it is entirely possible that prostate cancer screening could cause more harm than good. Therefore, at present, it is unethical to offer prostate cancer screening.

“In the future, screening should only be offered if the randomised controlled trials of prostate screening that are currently underway, demonstrate a benefit.”

The debate about prostate cancer screening has been quiet for a while.

One of it’s most memorable moments came on April Fool’s Day, 2004, when a Ministry of Health-hosted body called the National Health Committee made the following announcement: ‘No, not yet, to prostate cancer screening.’

The question remains: will those who didn’t get the joke then have any reason to laugh sometime later this year when the latest examination of this controversy that won’t go away reports back?

Making submissions to select committee: http://www.parliament.nz/en-NZ/PB/SC/MakeSub/

Email committee chair: paul.hutchison@parliament.govt.nz

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JUNE 19: STUFF.COM: Prostate cancer testing and treatment will be investigated by MPs after concerns the Health Ministry’s guidelines on testing are outdated.

Health select committee chairman Paul Hutchison said yesterday that it would hold an inquiry into optimal testing and treatment for prostate cancer, with specific terms of reference and a timeframe to be announced next Wednesday.

Dr Hutchison said several clinicians and other experts had expressed concern to him about current testing guidelines.

The Health Ministry does not recommend testing men with no symptoms, despite a 2007 study by Wellington researchers showing that early detection could save the lives of hundreds of New Zealand men each year.

However, other research including an article published this month in The New Zealand Medical Journal has concluded that up to 50 per cent of prostate cancer detected during testing would never have required treatment and that treatment could even be harmful.

Dr Hutchison said he was aware of that research, but said treatment methods had “improved remarkably” since 2004, when the guidelines were last reviewed.

“Of the 2000 men detected every year in New Zealand as having prostate cancer, something like 600 die,” he said.

“Two to three hundred men could be saved if early treatment was provided.”

Committee member and Green Party MP Kevin Hague said that, although prostate cancer was an important issue, the committee was the wrong forum to address it.

“There are … different specialist views and it requires considerable clinical judgment and skill to balance out those views.

“The select committee is a bunch of politicians that’s not our area of expertise.”

The Health Ministry was due to complete a literature review of nearly 300 pieces of recent research on prostate cancer testing and treatment in November, Mr Hague said.

“For the committee to undertake that work now risks duplicating work that’s already being done.”

But Dr Hutchison said select committees often dealt with complex issues and had the option of appointing committee experts.

The inquiry would complement the literature review and give ordinary people a chance to have their say.

TO SCREEN OR NOT

Experts are divided over the benefits of early screening for prostate cancer:

* PROS

Prostate cancer symptoms are not usually visible before the cancer spreads beyond the prostate. Screening can detect the cancer before this happens.

Early treatment is less expensive and has a higher success rate. Some research suggests up to 200 lives could be saved a year through early intervention.

* CONS

Some research has found about half of detected prostate cancer would never have caused symptoms or required treatment.

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JUNE 18: NZ PRESS ASSOCIATION: NZ Parliament’s health select committee has decided to hold an inquiry into prostate cancer, focusing on screening and early treatment. READ MORE>

Announcing the decision, the committee said it would release terms of reference after its next meeting on Wednesday next week (June 24).

Green Party MP Kevin Hague, a member of the committee, disagreed with the decision: “When politicians start making complex medical decisions, it’s dangerous and a recipe for disaster,” he said. “This is not the best way to develop health policy.”

Parliament’s select committees can hold inquiries into anything they want to and the health committee has carried out several in recent years.

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JUNE 16: NEW PROSTATE CANCER INFO-LINK:  The whole issue of the appropriateness of cancer screening is starting to become a major public health issue, closely and inevitably associated with cancer risk, writes Mike Scott. READ MORE>

“The New Prostate Cancer Infolink believes we can expect strong feelings to be expressed on both sides of this issue over the next few years, and we want to go on record now as stating that the currently available data for and against the appropriateness of screening for almost every form of cancer is generally very poor.

“We are never going to be able to resolve any of these issues until be get a lot better at at least some — and preferably all — of the following:

  • The early differential diagnosis of cancers by clinical risk — in other words, being able to have much better understanding at the time of diagnosis of who really needs aggressive treatment because their cancer may either shorten their life or severely affect its quality.
  • Explaining to individual patients why aggressive treatment may not be  in their best interests if they have every indication of low risk, indolent forms of cancer.
  • Alignment of physicians’ financial reimbursement with truly appropriate medical practice — so that a urologist (for example) is as reasonably compensated for convincing a 70-year-old patient that expectant management is probably an excellent form of care for his prostate cancer, given his particular circumstances, as the urologist would be for carrying out a radical prostatectomy.
  • Teaching society that the vast majority of cancer diagnoses have long since ceased to be a death sentence (although there are still plenty of exceptions to that statement).”

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tony ryall_29JUNE 15: PROSTABLOG NZ: Doctors looking for a steer from Health Minister Tony Ryall (right) on what his government has in store to address prostate cancer would have looked in vain at his speech on the opening day of the annual GPs conference.

The words were not mentioned in his address in Rotorua on Friday.

On June 5, he told Prostablog that prostate cancer is a priority for the new government.

To read the full text of his speech to the conference, CLICK HERE>

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JUNE 14: PROSTABLOG NZ: Ministry of Health officials and their medical advisers have been mulling over findings from the two large randomised studies of prostate screening in the US and Europe, and the ministry is due to make an announcement on the matter soon.

The Ministry has long advised the government that population-based screening has no proven benefits in terms of preventing death from prostate cancer, a stance echoed by the NZ Cancer Society, and some researchers, as well as by governments throughout the world.

Did the two big studies (published in March) find anything that will change their minds? And meantime, what should the average NZ patient do about screening (getting a GP to do a PSA blood test and a digital examination), and what treatment choice should someone make if a diagnosis is positive?

The Harvard Medical School website has a video discussing some of the issues. SEE IT HERE>Harvard

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