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Posts Tagged ‘early detection’

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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AUGUST 5: AMERICAN CANCER SOCIETY: In an effort to resolve confusion about what men need to be told about prostate cancer screening, the American College of Physicians has published advice to GPs about what they should advise patients. READ MORE>

For patients potentially interested in prostate cancer screening, physicians should engage them in shared decision-making; this is of even greater importance given the outcomes of the recent reports from the US
and European screening studies.

It is difficult for physicians to provide comprehensive and balanced information concerning prostate cancer screening decisions during a brief clinic visit.

The American College of Physicians has published a useful summary of discussion points to consider when counseling patients about prostate cancer screening:

● Prostate cancer is an important health problem.
● The benefits of one–time or repeated screening and aggressive treatment of prostate cancer have not yet been proven.
● DRE and PSA measurements can have both false–positive and false–negative results.
● The probability that further invasive evaluation will be required as a result of testing is relatively high.
● Aggressive therapy is necessary to realize any benefit from the discovery of a tumour.
● A small but finite risk for early death and a significant risk for chronic illness, particularly with regard to sexual and urinary function, are associated with these treatments.
● Early detection may save lives.
● Early detection and treatment may avert future cancer–related illness.

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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 9: Stiftung Prostrata, a Swiss trust focused on research into prostate cancer, has launched an eye-catching series of print advertisements encouraging men to take a blood test. What at first appears to be a series of men in their underwear turns out to be a demonstration of the power of early detection. SEE MORE>

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JUNE 27: OTAGO DAILY TIMES: Many men in New Zealand are suffering side effects after radiotherapy and surgery for prostate cancer which would never have killed them, and a screening programme would increase this, says University of Otago public health researcher Dr Brian Cox. READ MORE>

He was commenting on the recent announcement by chairman of the Health Committee Dr Paul Hutchison that the committee will conduct an inquiry into optimal screening (or early detection) and treatment of prostate cancer.

Dr Cox is concerned there is already considerable over treatment of men for this disease with very little evidence of any reduction in deaths from it.

Dr Cox, an epidemiologist, recently published an article in the New Zealand Medical Journal. READ IT HERE>

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JUNE 20: CHRON.COM:  Annual prostate screening is not necessary for all men, but getting a baseline PSA test at age 40 is a good idea, says a University of Texas M.D. Anderson Cancer Center urologist. The recently reported long-term European study of PSA testing clearly showed that early detection can work:  “People talk about it showing you have to treat 48 men to prevent one death. That’s true, but there was also a 41 percent reduction in metastatic disease, which is incurable. That translates to treating about 25 men to prevent one death, which is much more in the realm of what you want from early detection.” READ MORE>

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The Americans may have moved closer to the idea of national screening for prostate cancer, with a leading body recommending PSA tests for men aged 40.

Although the American Urological Association – which issued a new statement on testing this week – doesn’t actually say a national screening programme should now be implemented by the US government, its new stance goes further than previous guidelines.

With the notable exception of NZ Doctor, there has been no NZ media coverage of the US situation as yet, and cancer and government organisations in New Zealand may or may not be monitoring the debate.

If they are, the question arises: should this country be reviewing its “no national prostate screening” policy yet again?

The key points in the AUA’s statement yesterday are:

  1. PSA testing should be offered to well-informed men aged 40 years or older who have a life expectancy of at least 10 years;
  2. when offered and interpreted appropriately the PSA test may provide essential information for the diagnosis, pre-treatment staging or risk assessment and post-treatment monitoring of prostate cancer;
  3. a baseline PSA level above the median for age 40 is a strong predictor of prostate cancer. Such testing may not only allow for earlier detection of more curable cancers, but may also allow for more efficient, less frequent testing;
  4.  other factors such as family history, age, overall health and ethnicity should be combined with the results of PSA testing and physical examination in order to better determine the risk of prostate cancer;
  5. prostate cancer testing is an individual decision that patients of any age should make in conjunction with their physicians and urologists. There is no single standard that applies to all men, nor should there be at this time;
  6. the AUA does not recommend a single PSA threshold at which a biopsy should be obtained. Rather, the decision to biopsy should take into account additional factors, including free and total PSA, PSA velocity and density, patient age, family history, race/ethnicity, previous biopsy history and co-morbidities;
  7. the bottom line about prostate cancer testing is that we cannot counsel patients about next steps for cancer that we do not know exist.

So what’s changed?

Point 1: The first point about testing 40-year-olds is new. The aim appears to be to see what men’s natural PSA levels are (establish a baseline level) before they enter the prostate danger zone after about 50. Changes to PSA levels are a more significant indicator of trouble than actual level, so subsequent monitoring would note anything moving. At this stage, we don’t know what the AUA means by a “well-informed” man.

Point 2: This seems to be countering the standard arguments about national screening creating a risk of “over-diagnosis” and “over-treatment” – ie, men being persuaded into treatment when the cancer might be harmless. The AUA may be saying that used properly, the PSA is a more than useful test (not a view held by all in the medical profession).

Point 3: The radical idea of getting in so early (40) not only establishes a man’s baseline antigen levels, but gives a really early chance to apply treatment if something is found.

Point 4: This reinforces the point made in 2) – that done properly, this whole process works.

Point 5: Here, however, the AUA is having a bet each way, it seems. If something is found, the decision will still lie with the patient, suggesting we are not much further ahead in diagnosing what’s dangerous and what can be left for surveillance.

Point 6: This seems to broaden the criteria for considering a biopsy if the PSA shows something. A reinforcing clarification, perhaps.

Point 7: A number of interpretations could be drawn from this comment. It’s saying if we don’t test, how can we advise? Is this is an indication that the AUA is warming to the idea of national screening. 

Really, it’s not very clear what exactly the association is trying to say, and US media coverage has been muted and varying in its interpretations

All of these points may be clarified further when the AUA issues its formal guidelines soon.

For the full text of the AUA statement, click HERE> 

Ministry of Health policy on screening (2008) – HERE>

NZ Medical Journal paper on screening (2005) – HERE>

NZ Cancer Society policy on screening (1999) – HERE>

To vote in our poll on prostate screening, click HERE>

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