Written by: Dr Bensky
Ever since becoming a GP, the issue of prostate cancer screening has been an area of significant frustration for me. On the surface it does not seem so complicated – have a blood test (more about that later) and a rectal exam and we’re done. Unfortunately, until now, at least in my professional lifetime, there has not been agreement by the peak bodies in Australia regarding how to manage screening of the disease.
Here is a brief summary of their position statements.
– The Urological Society of Australia has supported routine screening of men over 55,
– the Cancer Council of australia have presented it as a conscience vote (ie discuss the pros and cons with your doctor/patient and them make your own mind up).
– The Royal Australian college of general practice have changed their guidelines in the last 2 years to essentially suggest that Gp’s should “respond to questions about prostate cancer (in other words don’t bring it up unless your patient does)
Fortunately for all of us, the Cancer Council of Australia, in collaboration with the other peak bodies is currently drafting a new set of guidelines that will act as a consensus statement in Australia regarding prostate cancer screening – with the hope of aligning all health practitioners regarding the screening of prostate cancer.
Now, to explain.
In order to have a meaningful conversation about prostate cancer screening, we first need to have a better understanding of what “medicine” does and does not know, and what “medicine” can and cannot do. The main point to make is that medicine is not a perfect science that does not have perfect tests or perfect answers – if we are able to move past this first hurdle (which for some patients and doctors is very difficult) then we can start the conversation.
This article does not intend to address issues of investigating or treating men who have abnormal symptoms or pre-existing prostate disease – but rather to address the question of whether well men should be having prostate cancer screening.
Conceptually, a screening test is a test performed on a person who has no symptoms or signs of a particular illness in an attempt to allow for an early diagnosis of a particular disease.
The 2 major objectives of a good screening program are:
- detection of disease at a stage when treatment can be more effective than it would be after the patient develops signs and symptoms, and
- identification of risk factors that increase the likelihood of developing the disease and use of this knowledge to prevent or lessen the disease by modifying the risk factors.
It is important to acknowledge that prostate cancer is a common disease – almost 20 000 men are diagnosed with it in Australia each year and 3300 men die of it. This makes is the 2nd highest cause of male cancer deaths in Australia and the fourth most common cause of male deaths in Australia overall.
There are two main studies that are regularly quoted in relation to prostate cancer screening, one from Europe and one from the United States. Unfortunately, the findings of these two studies are at loggerheads with each other, with the the US Prostate, Lung, Colorectal, and Ovarian Cancer Screening (PLCO) Trial finding no benefit of annual screening, whilst the European Randomized Study of Screening for Prostate Cancer (ERSPC) found a statistically significant fall in prostate cancer deaths in those screened for prostate cancer. Australia’s National Health and Medical Research Council (NHMRC) recently concluded that there is currently no way of knowing if prostate cancer screening is of benefit to improving quality of life or length of life.
Thus, the tough pill that we all need to swallow is that no one can say with complete clarity what is the “right” thing to do. Each one of us needs to determine how we are going to face the dilemma of what to do in the face of uncertainty. For each individual, having these tests done could facilitate the early diagnosis of potentially life threatening illness, thus extending life and improving its quality. On the other hand, it may lead to unnecessary overtreatment and have no positive impact into a person’s length or quality of life. The catch-22 we find ourselves in means that the mantra of “ I want to be proactive/healthy thus I would like to be tested” does not work as well as what we would like.
The new draft recommendations conclude:
- For men informed of the benefits and harms of screening who wish to undergo regular testing, offer PSA testing every two years from age 50 to age 69 – in other words, we should not, at this stage implement a blanket screening program in Australia, but rather continue to discuss the pros/cons of screening and use this information to make our own decisions.
- men who are in a higher risk group with 1st degree relatives can be offered screening from 45
- men under the age of 45 should not be screened for prostate cancer
- digital rectal examination is not recommended as a routine test in the primary care setting