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

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

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

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

“We really cannot leave things as they are.”

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

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

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TonyMAINPROSTABLOG 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.

TonyMAIN2But 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.

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JULY 30: PR NEWSWIRE.COM: Oncologists expect to prescribe the new vaccine for advanced prostate cancer,  Provenge, to 54 percent of patients with asymptomatic hormone refractory metastatic prostate cancer. READ MORE>

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JUNE 1: NEW YORK TIMES:  “My goal last fall was to recover from surgery for prostate cancer and to slog through radiation and hormone therapy. My goal this fall is to run a marathon,” writes journalist Dana Jennings. “In the last year, my body has belonged to urologists and insurers, surgeons and oncologists, nurses and radiation therapists. It belonged to my cancer. By running again, I’m reclaiming ownership of my body.” READ MORE>

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MAY 11: PROSTABLOG NZ:  Anyone doubting the significance of the two long-term prostate cancer testing studies just published in the US need only read a NZ Medical Journal paper published late last year by leading Kiwi urologist Robin Smart.

He accurately predicted the studies “may or may not” resolve debates about national screening and making more information available to GPs and patients.

The studies have had mixed reviews, but, as Smart says, they add to a vast body of knowledge that overwhelmingly supports the value of PSA, digital examination and biopsy testing.

He laments a lack of technology and promotion of information about testing in NZ that could save up to half the 600 men who currently die of proistate cancer here each year, a figure that is static, compared to big improvements in Western Europe, the US and Australia.

He says our government’s antagonistic attitude to prostate cancer information dissemination puts us with the backward practices of Eastern Europe, where adoption of modern methods and testing (including PSA), has resulted in increasing death rates.

He points out that statistics quoted to rebuff calls for national screening are well below those accepted for NZ breast and cervical cancer screening programmes.

His conclusions (full paper available to NZ Medical Journal subscribers only):

“An overwhelming body of evidence shows that PSA/digital rectal examination testing leading on to TRUS (ultrasound) biopsy and curative treatments (where indicated) has been a major advance for men’s health.

Indeed, those with significant experience of dealing with men with this cancer in pre-PSA times appreciate the difference only too well.

Then, 70% had metastases at diagnosis and the mortality ratio was 41%.

Studying the fate of control group men in the various trials outlined above, especially those in Bill-Axelson and Holmberg’s trial, provides a chilling reminder of the potential for this cancer to ruin or end a man’s life in his later years.

It is true that these improvements in morbidity and mortality have come at a price of more investigation and treatment. Numbers of men diagnosed with prostate cancer have approximately doubled.

But this is the inevitable price for better results. The first-line investigations of PSA, DRE, and TRUS biopsy have been shown to be well tolerated and safe in an office setting.

It is important that men with insignificant cancer, or major comorbidity, or limited projected lifespan, get appropriate management, including surveillance only or other minimal approaches. It is also important that men with threatening cancers get these recognised in time for curative treatment.

A special group are those with a family history of prostate cancer. The usual lifetime risk of 12% doubles if one first-degree relative has prostate cancer and increases by 5 to 7 times if more than one has it.  Therefore, potential benefit of PSA testing includes not just the individual but also his family, and there is evidence that the outlook for family members is improved by PSA/DRE testing.

Before PSA testing, the outlook was worse for those with a family history compared to the general population but now it is better. This is considered to be due to a greater awareness and earlier testing by relatives of those with prostate cancer.

The dramatic improvements in morbidity and mortality from prostate cancer in Western Europe, North America, and Australia outlined above have occurred because a very large proportion of the middle aged and older men in those countries have undergone PSA and DRE testing.

The drive for this remarkable change has occurred at community level amongst men, their families, and family doctors on learning about this technology as a way to avoid advancing prostate cancer.

Governments generally have been neutral or antagonistic about PSA testing.

For example, the British National Health Service states: “Opportunistic screening (with PSA) should be discouraged” and the New Zealand Guidelines Group (NZGG) in 2004 stated several times in its information for practitioners that PSA “Not recommended as a screening test in asymptomatic men.”

New Zealand has not shared the improvements in prostate cancer mortality experienced by other advanced Western nations including Australia detailed above. Rather, our annual mortality has been static at about 600, similar to eastern European countries.

Large numbers (more than 2000) of men are now diagnosed with prostate cancer in New Zealand each year. But there have been powerful discouragements to men contemplating PSA testing and their family doctors resulting in uncertainty and confusion.

This includes not just the efforts of the NZGG, but also studies originating in the New Zealand Ministry of Health critical of general practitioners screening with PSA and DRE.

Many general practitioners are ambivalent about it as a result. Some have adapted by only referring on men with higher PSAs, for example 8 or more. This author’s experience has been that the most recent 300 TRUS Biopsies have a mean referral PSA of 11.1, and the last 100 radical prostatectomies—a mean referral PSA of 8.4.

Others actively discourage PSA testing and disseminate that view.

A common argument used is that 450 men must be screened to save 1 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 that for cervical cancer screening 8000. It seems likely that New Zealand men have not been tested as much, and perhaps sometimes been referred later (compared to men in Australia, North America, and Western Europe), to explain the difference.

Access to investigations and treatments may be poorer in New Zealand than the other countries, especially for the two-thirds of the population without health insurance.

Of course, most New Zealand general practitioners exercise great care in dealing with this issue.

The NZGG this year (2008) formed an ‘advisory group’ comprising representatives of the Prostate Cancer Foundation, radiation oncologists, urologists (including this author), the Cancer Society, the College of Pathologists, general practitioner, and Maori to formulate more information material.

The “non-Ministry” members of this group strongly favoured the NZGG providing men contemplating PSA/DRE testing with information about the advances discussed above, including changes internationally in prostate cancer mortality and trials. It was considered that men making such a decision at this time were entitled to this information.

The institution of a national screening programme was not advised, but provision of this information to men was.

But the draft containing this advice was rejected, the NZGG citing its contract with the Ministry and opting for neutrality. An opportunity [was] lost to improve prostate cancer results in New Zealand as has occurred in other countries.

To be fair to the NZGG, other government authorities internationally have adopted a similar neutral or opposing stance. And, as with any field of human endeavour, papers continue to be published expressing scepticism about PSA/DRE screening.

The long-awaited analysis of the ERSPC and PLCO trials, already put off from 2008 for a few years, and which have cancer mortality as end points, may resolve the debates. Or may not. There are many potential problems with these huge multicentre trials, not least of which is occult cross over from control to PSA groups. Initial results, as discussed above, support PSA/DRE testing.

The weight of evidence in favour of PSA/DRE testing is now overwhelming after almost two decades of international experience. To go back to the time before PSA testing would now be unthinkable.

Of course we hope for the perfect tests, perfect treatment, and continue to look for improvements. But New Zealand men today need the benefit of current technology which the evidence shows could save between 200 and 300 of the 600 who currently die of prostate cancer each year.

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