Maori and prostate cancer – latest research shows shocking trends haven’t improved

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

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

Some quotes from the report:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Read Full Post »

Why has it taken so long for prostate cancer cell detector to arrive in Australasia?

PROSTABLOG NZ:  Australian news media are breathlessly reporting that a “new” prostate cancer diagnostic tool, the cell search machine, is being set up in their country for the first time (in Brisbane). READ MORE>

Should we be excited? Yes – that this technology – used in the US for more than five years – is finally appearing in our part of the world (although not yet in NZ).

My gripe is not about the news itself, but the way ill-informed journalists report such announcements, swallowing the official spin without question.

The real story lies in challenging governments over the delays that attach to such breakthroughs making their way Down Under.

Has anyone thought to ask NZ or Australian ministries of health how long it will be before Provenge (a new treatment for advanced prostate cancer) is available here?

Read Full Post »

NZ Ministry of Health releases latest cancer death figures – prostate way up there

PROSTABLOG NZ: For NZ males, prostate cancer accounted for 28.6 percent of all cancer registrations in 2007, reports the NZ Ministry of Health, with the next-most-common registrations being colorectal cancer and malignant melanoma of the skin. READ MORE>

Read Full Post »

Prostate screening story doesn’t change much in NZ

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

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

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

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

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

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

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

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

Did they?

Are there more hearings?

When will we see the results?

Read Full Post »

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

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 interests 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>

Read Full Post »

NZ government issues new guidelines to GPs on how to handle prostate cancer patients

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

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

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

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

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

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

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

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

Men with erectile dysfunction are excluded from the referral guidelines.

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

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

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

Read Full Post »

NZ health ministry publishes new set of guidelines for cancer nurses

JULY 31: NZ MINISTRY OF HEALTH: A set of guidelines for registered  working in cancer control has just been published by the New Zealand Ministry of Health. READ MORE>

Read Full Post »