Posts Tagged ‘Over-treatment’

PROSTABLOG NZ:  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.

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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.

READ full submission here>

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URO TODAY: The common claim that PSA testing leads to high and unacceptable levels of prostate cancer over-detection – and therefore over-treatment – is an exaggeration, according to a presentation at the 107th annual meeting of the New York Section of the American Urology Association. READ MORE>

In this 69-page slide presentation, Dr William J Catalona – the US “father” of the PSA test – analyses a number of studies of PSA testing and seeks to discredit those which show testing leads to over-diagnosis and treatment:

Over-detection is a relatively small issue when considered in the context of the larger issue of preventing suffering and death from prostate cancer, especially when good clinical judgement is used and patients receive appropriate, effective and high quality treatment.

He is critical of what he calls the premature reporting of two big randomised studies of PSA testing earlier this year, saying much more followup time is needed before meaningful results can be obtained.

Notwithstanding that, Dr Catalona – a professor at Northwestern University in the US –  refers to the European study (ERSPC) in making this observation about whether men should choose to be tested:


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PROSTABLOG NZ: For now, the debate about whether all men should be screened for prostate cancer is dead.

For now.

For sure, it will re-ignite at some future time, as prognostic tests are improved to the point where doctors can tell when  a prostate tumour discovered in a man needs treatment and when it can be left alone.

Why is the debate dead in the meantime?

Two studies published by the British Medical Journal today back up what most analysts have been saying since the March publication of early results of the two big randomised trials that have been looking at PSA/digital testing.

That mass screening will uncover a lot of cancers that are harmless. Over-treatment will result. It has already.

Even the NZ Prostate Cancer Foundation appears to have conceded this is the case.

At last week’s initial hearings by the Parliamentary inquiry into prostate cancer, Foundation president Barry Young said the organisation was “not dogmatic” about screening.

So where does this leave things?

Should we abandon PSA and rectal exams?

Hardly. They are reliable tools for diagnosis and must still be available to men who ask for them, men whose families have a history of prostate or breast cancer, men with symptoms like reduced urination, unexplained pains, blood in the urine, etc.

Where the debate still needs to continue is in the arena of primary health: how can the confusion that appears to reign among GPs and their patients be clarified.

And does all this rule out a marketing campaign urging men to be checked?

No way. It just needs to be done with a clear message.

Not a lot to ask.

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AAFP NEWS NOW: Men shouldn’t just rush in to get screened for prostate cancer, says a US family doctor organisation – they need to talk it over with their physician first.

The American Academy of Family Physicians is warning the world-wide Blue September prostate cancer awareness campaign may be confusing men and their doctors. READ MORE>

In recognition of September as National Prostate Cancer Awareness Month, many of your male patients (and their wives) may have been reading, hearing and seeing news reports, commercials and public service announcements encouraging men to be screened for the disease.

However, the AAFP has concluded that current evidence is insufficient to assess the balance of benefits and harms of prostate cancer screening in men younger than age 75, and the Academy actually recommends against screening men 75 and older.

Those AAFP recommendations agree with those of the US Preventive Services Task Force.

The academy quotes family physician and USPSTF member Michael LeFevre, who says the vast majority of the messages coming from professional medical and consumer health organisations and public health agencies about prostate cancer screening are consistent in saying that:

…men should be given all the information they need to make informed decisions about whether to be screened for prostate cancer.

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URO TODAY: Studies are needed to better delineate how active surveillance can be used to reduce over-treatment and optimise quality of life, while maintaining the survival benefits of selective treatment. READ MORE>

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URO TODAY: PSA screening reduces the risk of dying of prostate cancer by up to 31% in men actually screened, and this benefit should be weighed against a degree of over-diagnosis and over-treatment inherent in prostate cancer screening. This finding comes from deeper analysis of the large randomised European study reported earlier this year. READ MORE>

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URO TODAY: Guidelines on “watchful waiting” or “active surveillance” as options for those diagnosed with prostate cancer reflect a changed attitude towards treatment in the light of the early detection of these tumours and the data now available regarding active surveillance. READ MORE>

A corresponding change in actual medical practice would be desirable. The treatment of prostate cancer should always be adapted to the individual needs of the patient, and risky treatments should only be used when absolutely necessary.

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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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JULY 31: URO TODAY: If population-based screening and testing were adopted in the UK, five times as many men would be diagnosed with prostate cancer, a new study has concluded. READ MORE>

Researchers at the Department of Social Medicine, University of Bristol, report:

If population-based PSA testing were introduced in the UK, approximately 2660 men per 100,000 aged 50-69 years would be found to have prostate cancer, compared to current rates of approximately 130 per 100,000.

If half of men accepted PSA testing, approximately 160,000 cancers would be found, compared to 30,000 diagnosed each year at present.

Population-based PSA testing resulted in a significant downward stage and grade migration, and most such cancers were of low stage and grade, which could lead to risks of over-treatment for some men.

Mike Scott (New prostate Cancer Infolink) has this to say about the study:

What this study does do…is identify the real clinical value of a test that could actually discriminate with accuracy, early on between those patients at real risk for clinically significant disease (apparently about 30,000 per annum in the UK) and the 130,000 who might be identified with histologically identifiable but clinically non-significant disease.

That’s an awful lot of men who could benefit from knowing early on what their real risk might be for clinically significant disease — one way or the other!  READ MORE>

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