PROSTATE INQUIRY

How does ‘encouraging’ men to have PSA tests differ from mass screening?

PROSTABLOG NZ 2/4/2011: 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 options…including 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.

Dear Dr Hutchison and colleagues…here’s some advice

PROSTABLOG NZ 25/09/2010:  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.

Year has passed and no news from NZ’s parliamentary inquiry into prostate cancer

September 12, 2010: 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).

Urologists take more balanced view of prostate cancer testing in submission to NZ parliamentary inquiry

October 22, 2009 by Jim Tucker | Edit

PROSTABLOG NZ: Not surprisingly, NZ urologists – the doctors who operate on prostate cancer patients – are more circumspect than the country’s health bureaucrats when it comes to assessing the value of PSA and digital tests.

That became obvious at this week’s hearings by the Parliamentary Health Select Committee inquiry into prostate cancer detection and treatment.

A submission by the Urological Society of Australia and NZ takes a more balanced view of testing than those allied to the Ministry of Health, who gave their evidence last month and expressed strong opposition.

The society says, in essence, that PSA tests and digital exams aren’t foolproof, but if used judiciously – that is, in conjunction with other diagnostic methods and with proper consultation with patients – they undoubtedly save lives.

Along with many overseas groups, they urge more research to find better markers, and particularly recommend the development of protocols to enhance the option of active surveillance.

Here is their submission:

NZ prostate inquiry first day: battle lines drawn between prostate community and medical bureaucrats

September 24, 2009 by Jim Tucker | Edit

PROSTABLOG NZ: The battle lines were drawn at yesterday’s first hearing of the  NZ Parliamentary inquiry into prostate cancer – “vested interests” versus those who guard the country’s public medical system.

The former group, apparently, comprises prostate cancer patients and some medical professionals who operate in the field of prostate cancer; the latter, the NZ Guidelines Group, a committee from the medical fraternity and bureaucracy on whom the Ministry of Health relies for expert advice on health policy.

According to the Guidelines Group, the vested interests (a term they used at today’s hearing before the Health Select Committee) must be excluded from the process of deciding how or whether prostate cancer testing should be funded and implemented.

PROSTATE INQUIRY: Barry Young gives his submission.

This proposition alarmed some members of the select committee, who asked if the reference to “vested interests” referred to drug companies or other commercial interests who might benefit from prostate screening and testing.

The Guidelines Group – represented by chair Professor Cindy Farquhar, chief executive Steve Caldwell and a Nelson GP, Dr Jim Vause – seemed reluctant to spell out exactly what they meant, but when pressed conceded it was, in part, people who suffer from the disease being discussed.

It was a crucial moment at yesterday’s hearing, a three-hour session during which the committee of MPs heard evidence from mostly those in the “vested interests” corner – prostate survivors and their medical advocates.

It threw into sharp relief the attitude of those whose opposition to screening and testing have influenced the government’s position on prostate cancer for more than a decade, a decade during which medical science has moved rapidly to outflank some of their views.

The battleground was forcefully defined from the start of the hearings, when Prostate Cancer Foundation president Barry Young (see video) gave a passionate outline of what he termed the unnecessary loss of men’s lives because of confused communications between the Ministry of Health, GPs and patients.

He and Professor Brett Delahunt – an eminent Wellington pathologist who specialises in urology – claimed earlier attempts (in 2004) by the NZ Guidelines Group to produce policy on prostate cancer testing were a fiasco, which dishonestly misrepresented the outcome as the consensual work of the specialists involved (who included Delahunt).

The MPs were taken aback by these claims and will provide the Guidelines Group with a recording of what Young and Delahunt said so the group can respond (interestingly, the Guidelines people were last up today, so they didn’t attend the earlier submissions to hear what was said).

Health Select Committee chair Paul Hutchison (right) guides the hearing.

All the submissions yesterday were effective.

Three prostate survivors – one a former medic with the NZ army in Vietnam – gave different perspectives on their experiences, and were questioned closely by the MPs on what they think the committee can do to meet the challenges.

The most affecting presentation came from Kim Cook (Mary on this blogsite), whose story about partner Brian’s saga with advanced prostate cancer deeply affected those listening to her by teleconference.

Veteran MP Eric Roy (right) could be seen wiping tears from his eyes, and most in the room were not far removed from such a show of emotion.

Kim’s efforts to empower herself in the face of a seemingly implacable medical profession were accorded great respect by the committee.

As second man up, Barry Young told the committee that “some members of the medical profession have not distinguished themselves at all” in the way they have dealt with prostate cancer.

“The attitude of some members has indeed led to the death of men in this country,” he said. These were men who had been refused the option of PSA tests or rectal exams or both.

When men came to the foundation in desperation in such circumstances, the foundation’s advice was for them to find another GP.

“We need an education programme not only for the public but for the medical profession as well.”

He was critical of the process used by the Ministry of Health to formulate its policies on prostate cancer screening.

He described an earlier instance when he and prominent prostate specialists were invited on to a Ministry-funded committee to investigate research and best practice.

When it was completed, the committee was disbanded and to his alarm the Ministry’s advisors declined to have the resulting policy peer-reviewed.

“None of us recognised a single paragraph of the policy report that was produced. I can understand why GPs are confused.”

Later, he was asked by Eric Roy why some GPs were not offering screening.

“I think it’s because they are confused. Even the information given to urologists is less than clear. We need to remove the ambiguity – from the medical profession, from the Ministry of Health.”

Brett Delahunt (left) was even more condemnatory of the Ministry’s policy advice process, describing the last instance by the NZ Guidelines Group in 2004 as a “fiasco”.

He was invited onto that review committee late in the procedure and went to its last two meetings.

He felt his views and those of other specialists involved were largely ignored.

“The recommendations of the Guidelines Group [for GPs not to recommend PSA testing to asymptomatic male patients] were not a consensus. They were inflicted on the committee after the meetings.”

The problem with such a policy was that in most cases, by the time men showed symptoms, the cancer had spread and metastasised, which meant it was too late to treat them: “If you wait for symptoms to occur you’ve left it too long.”

The PSA (prostate-specific antigen) was the most sensitive of all cancer markers. The false negative rate was “quite low” if the procedures were properly handled.

What the clinician should look for is change in the level of PSA. If the level began to double in less than a year, the approach should be aggressive.

He believes it is now possible to tell the difference between indolent and aggressive tumours.

He described the confusion initially caused when researchers used data including the early use of the Gleason score (for cancer aggression) which once included grades 1 and 2.

It has since been found that samples showing such low scores were not cancers at all (so the Gleason scale no longer includes them), but treatment and mortality data used to compare trends had been muddied as a result.

He said other governments (Canada, US and some in Europe) show a much more positive approach than New Zealand’s to screening and to making men aware of the dangers of slow-growing prostate cancer.

Evidence of the success of opportunistic screening (as opposed to population-based) was now overwhelming.

Chair Paul Hutchison (right) asked for elaboration about Delahunt’s Guidelines Group comments, saying he was under the impression the group was independent and very anxious to take an evidence-based approach.

Delahunt: “That’s fair – but the evidence base was out of date.” He also said he became a member only through accident, after a colleague in Australia mentioned to him the process was under way and asked why he was not part of it.

He said when the group’s guidelines were published his name was listed on the document, something he objected to, since he disagreed with its negative tenor: “There was an element of dishonesty in the Guidelines Group thanking us for the work done.”

Challenged by MP Ruth Dyson (left) on what she perceived to be an allegation the medical profession was deliberately not doing its best, Delahunt said he did not believe anyone went out of their way to deter men from being diagnosed.

His assertion was that some men with the potential to have the diagnosis and cure were missing out.

Asked by Green MP Kevin Hague who should make the decision about a screening programme, Delahunt said he was not proposing a national population-based programme. The need was to encourage opportunistic screening.

“This committee should tell the medical profession there is a need for more clearcut guidelines.”

Hutchison asked who would be in a position to achieve that.

Delahunt: “A balanced group could be appointed.”

Later, he added that some men were not getting a fair deal. Roughly the same number of men died from prostate cancer as women from breast cancer.

The Guidelines Group trio was last to speak (rather mysteriously “welcomed back” by the committee), with GP Jim Vause leading the committee through a series of PowerPoint slides.

These included simplified graphics illustrating what he perceived to be the main thrust of results from the two randomised studies: ie. that many men (more than 1400) need to be screened for prostate cancer before a single life is saved.

He did not mention that many more women (thousands) need to be screened for breast and cervical cancer before their single lives are saved.

Hutchison pointed out that there were known problems with the two trials. Vause said he would get to that later, but didn’t.

He showed that the NZ prostate cancer death rate has been stable since 1961, but that since the early to mid-1990s, the number of diagnoses has risen steeply.

He put that down largely to the prostate awareness programme (but Bret Delahunt would give a big share of the credit to the introduction of the PSA test in 1993).

He was at pains to warn of the risks of treatment – especially death.

A key slide shown to the committee said: “[There is a] need for presenting information free of bias from vested interested in an (sic) manner that a man can understand.”

He said he believed the key point in all this is informed consent.

Guidelines Group chair and surgeon Cindy Farquhar (right) said it was vital to have reliable evidence when introducing a new strategy.

This involved trade-offs between:

• benefits of intervention (in this case a screening programme to detect early prostate cancer);
• risk of the intervention (harms from the additional biopsies, downstream treatments);
• cost of intervention;
• patient preferences.

She mentioned the downside of “just doing it”, listing three examples from the past when such an approach proved  disastrous.

Her last slide elaborated the Guideline Group’s processes:

• systematic approach;
• researchers with expertise in clinical studies, critical appraisal, combining studies, developing recommendations, grading evidence;
• developing guidelines – how to apply the international evidence to the NZ health sector.

The main message from her group was that its review of the two overseas studies (reported in the New England Journal of Medicine last March) was still going on and would not report until November.

Hutchison asked for an assurance that would be done on time, got it, and said the committee would look forward to hearing from the group once that had happened.

The MPs were impressive during yesterday’s hearing.

It was obvious they had done their reading. Their questions showed they have a sound grasp of the issues they must somehow try to resolve.

In the end, it came down to a couple of straight-forward questions:

• How can the confusion that seems to abound between patients and doctors over prostate cancer be resolved?
• What can be done to break through Kiwi males’ “I can tough it out” attitude to getting themselves checked out?

The committee made it clear that sorting out the vast morass of conflicting data about prostate cancer detection and treatment is not its job – it will probably recommend this be done by a truly independent group representing all stakeholders, “vested interests” and all.

The only thing everyone seems agreed on at this stage is that population-based mass screening of all men for prostate cancer is not a starter.

But neither is the status quo acceptable. Leaving men without symptoms out of the equation (the medical bureaucracy’s current stance) won’t do.

FOOTNOTE: Committee chair Dr Paul Hutchison said after the hearings that he would write to Barry Young and ask him to provide details to the Health and Disability Commissioner of any cases the foundation knows about of men being refused PSA tests by their GPs.

NEWS COVERAGE of the hearing

NZPA : Hundreds of men are unnecessarily dying of prostate cancer every year because doctors refuse to test them, a parliamentary select committee has been told.  READ MORE>

TVNZ: New Zealand specialists say men as young as 40 should have regular prostate checks, because they believe waiting until 50 is just too risky. READ MORE>

RADIO NZ: Parliament’s health select committee has distanced itself from accusations some doctors are responsible for the deaths of hundreds of men from prostate cancer. READ MORE>

SEPTEMBER 22: PROSTABLOG NZ: Mary and John -whose prostate cancer story appears on this website – will get their 15 minutes of fame tomorrow before the first hearing of the NZ Parliament’s inquiry into the disease. READ MORE>

Inquiry into early detection and treatment of prostate cancer

Health Select Committee Terms of reference:

1.    To seek 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). This will also include the results of the New Zealand Guidelines Group screening review due in November 2009.

2.    To seek 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.    To seek best methods to promote awareness for early detection and treatment of prostate cancer.

4.    To seek a cost benefit analysis, if appropriate.

SEPTEMBER 1:

Article by Dr Paul Hutchison

Published 0n Dominion Post Opinion Page – September 1, 2009

THE widespread confusion many men feel over the advice they receive on early detection and treatment of prostate cancer is untenable.

That a leading New Zealand urologist, Robin Smart, recently concluded ‘‘the evidence suggests that between 200 and 300 of the 600 men who die annually of prostate cancer could be saved by current technology’’ indicates greater efforts need to be made.

He says, ‘‘there have been powerful discouragements to men contemplating PSA [blood] testing, and their family doctors, resulting in uncertainty and confusion’’.

Because of this, I felt it important to launch an inquiry. This call has been taken up by Parliament’s health select committee. The inquiry is into ‘‘the early detection and treatment of prostate cancer’’. Submissions close next Monday.

About 2000 cases of prostate cancer are diagnosed each year. In a helpful but, I believe, cautious pamphlet published last year, the New Zealand Guidelines Group noted the chances of a diagnosis of prostate cancer for: A man in his 40s: 1 in 500 men. In his 50s: 1 in 50. In his 60s: 1 in 14. In his 70s: 1 in 9. What is startlingly clear is that ‘‘if you have a close relative with prostate cancer, your risk of developing cancer is increased’’.

I have no doubt that New Zealand men should be made clearly aware of the risk factors because increasingly effective diagnosis and treatment are available.

There is ongoing debate as to the optimal early detection and treatment of prostate cancer. Dr Smart wrote in the December New Zealand Medical Journal: ‘‘An overwhelming body of evidence shows that PSA, prostate specific antigen [a blood test], and digital rectal examination leading on to transurethral ultrasound biopsy and curative treatments [where indicated], has been a major advance for men’s health.’’

On screening, Dr Smart says a common argument used is that 450 men must be screened to save one from dying of prostate cancer (a figure which is disputed), and that this is too large to make screening worthwhile.

But the equivalent figure for breast cancer screening is 1700, and for cervical cancer screening 8000.

Dr Smart’s views are more closely supported by other clinicians, such as Professor David Lamb and Professor Brett Delahunt of the Wellington School of Medicine. They wrote in Pathology in 2007 that there is now compelling evidence that:

‘‘Cancers diagnosed by screening are more likely to be early stage, when most can be cured by several treatment options.

‘‘The maximum benefits for screening are for men aged 50-70.

‘‘Men with one or more firstdegree relatives already diagnosed with the disease should be actively encouraged to undergo screening.’’

Two major trials on prostate screening (one in Europe and the other in US) were published this year and were hoped to bring greater clarity to the issue.

The New Zealand Guidelines Group is due to report by November on an extensive literature review on the effectiveness of screening asymptomatic men.

Associate Professor Brian Cox, an epidemiologist at Otago University, writing in the New Zealand Medical Journal in June, concluded: ‘‘Trial evidence suggests that claims of benefit from PSA testing in asymptomatic men have probably been overstated and the recognised harms must be rigorously considered to protect men from iatrogenic (doctor caused) illness.’’

The Australian Senate received recommendations in May from its select committee inquiry on ‘‘men’s health’’.

The Australian report quoted the recommendations of the Prostate Cancer Foundation of Australia, which are that ‘‘all men from age 50 onwards would go to his GP and have a conversation about prostate cancer, they should have the blood test, the PSA, and they should have a physical digital rectal examination to feel whether there is any growth in the prostate’’.

The report concludes: ‘‘Prostate cancer is the most diagnosed cancer in Australia. At present the information available to those with prostate cancer and the services to support them are not adequate.’’

The same situation exists here. The New Zealand Prostate Cancer Foundation is responsible for an awareness campaign, Blue September, starting now.

While it is wrong to raise unrealistic expectations, the aim of stronger action is to avoid preventable deaths. I believe it is fundamental that New Zealand men are able to receive the best possible evidenced-based advice in a clear, concise way.

Dr Paul Hutchison is MP for Hunua and chairman of the parliamentary health select committee.

AUGUST 21

Prostablog poll has message for Health Select Committee inquiry into prostate cancer

by Jim Tucker | Edit

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 closed 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?

Some tough questions for the NZ parliamentary inquiry into prostate cancer

August 18, 2009 by Jim Tucker | Edit

PROSTABLOG 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.

But 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.

Early detection and treatment of prostate cancer

Health Select Committee Terms of reference, July 20, 2009

The terms of reference for this inquiry are as follows:

1.    To seek 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). This will also include the results of the New Zealand Guidelines Group screening review due in November 2009.

2.    To seek 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.    To seek best methods to promote awareness for early detection and treatment of prostate cancer.

4.    To seek a cost benefit analysis, if appropriate.

The committee is now calling for submissions. The closing date for submissions is Friday 21 August 2009.

The committee requires 2 copies of each submission. Those wishing to include any information of a private or personal nature in a submission should first discuss this with the clerk of the committee, as submissions are usually released to the public by the committee.  Those wishing to appear before the committee to speak to their submissions should state this clearly and provide a daytime telephone contact number and an email address.  For further guidance on making a submission, our publication Making a Submission to a Parliamentary Select Committee can be found on our web site at http://www.parliament.nz/en-NZ/SC/SubmCalled/.
Submissions should be addressed as follows:

Secretariat
Health Committee
Parliament Buildings
WELLINGTON

Contact for further details:
Fenella Bovett on  (04) 817 9549 or select.committees@parliament.govt.nz

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