PSA testing guidelines proposal - our response

[JimJimJimJim]

My thanks and congratulations to Committee members Paul Edwards and Alan Barlee on the preparation of the following response on our behalf under considerable time pressure.

Jim Marshall

 

Submission on Draft Clinical Practice Guidelines PSA Testing and Early Management of Test-Detected Prostate Cancer

 

This submission is made on behalf of the Australia Advanced Prostate Cancer Support Group.  The members of our Group are men with advanced prostate cancer from all over Australia.  We have monthly meetings via teleconference and conduct an online discussion forum at www.JimJimJimJim.com

 

At the 2013 Prostate Cancer World Congress a group of leading prostate cancer experts from around the world produced The Melbourne Consensus Statements on Prostate Cancer.

 

Compared with the simple easy-to-understand guidelines in The Melbourne Consensus Statement, the Draft Clinical Practice Guidelines are complex, at times confusing and difficult for practitioners and patients to interpret.

 

We agree with the Melbourne Consensus Statement 2 that Prostate cancer diagnosis must be uncoupled from prostate cancer intervention.  The problems and potential harm comes not from PSA testing but from the interventions which occur after PSA testing.

 

We are concerned that the Draft Guidelines recommend a high volume random prostate biopsy as the first investigation of a raised PSA.  We are concerned that the Expert Advisory Panel (which did not have the benefit of an expert prostate “Radio-Urologist”, or “Uro-Radiologist” amongst its members) has either ignored, or has not paid sufficient regard, to the recent developments in imaging and targeted biopsies.  We support the comments made by Drs Thompson and Parkinson in their submission dated 10 December 2014 on the Draft Guidelines.

 

We agree with the Melbourne Consensus Statement 2 that PSA testing should not be considered on its own, but rather as part of a multivariable approach to early prostate cancer detection.   PSA testing should be combined digital rectal examination, prostate volume, family history, ethnicity, risk prediction models, and new tools such as the phi test.

 

The Draft Guideline that a DRE is not recommended as a routine test in the primary care setting is based on very limited evidence.  

It is contrary to findings of the 2013 Report on Prostate Cancer in Australia by the Australian Institute of Health and Welfare:

“Irregularities such as swelling, hardening or lumps on the surface of the prostate may be signs of prostate cancer (American Urological Association 2007; Andrology Australia 2011). Although not all prostate tumours are palpable (able to be felt), a DRE may detect prostate tumours that do not produce abnormal PSA levels and therefore would not be picked up by a PSA test alone.”  

We also refer to the following article by Associate Professor Nathan Lawrentschuk and Mr Damien M Bolton in the Medical Journal of Australia:

“The digital rectal examination (DRE) is an integral skill in clinical examination. It can be used to identify abnormalities of the anus and rectum, including rectal tumours, to characterise the prostate and assess gynaecological conditions, and to assess anal tone as part of a neurological or orthopaedic examination.  A third of rectal cancers are palpable on DRE, while an abnormal prostate on DRE may have a positive predictive value for prostate cancer of up to 30%.  Omitting a DRE may delay referral of patients with a potentially resectable carcinoma.  Thus, DRE is an essential skill for all medical students to acquire.” (www.mja.com.au/journal/2004/181/6/experience-and-attitudes-final-year-medical-students-digital-rectal-examination)

 

There is evidence that PSA testing with or without DRE reduces the risk of prostate cancer metastases at diagnosis compared with no PSA testing (see the 2013 Report on Prostate Cancer in Australia by the Australian Institute of Health and Welfare).

If it is possible to diagnose someone with prostate cancer at a time when it can be treated and cured, then we believe that this should be done, rather than waiting until the prostate cancer has metastasized and is incurable.  As men with advanced prostate, we are only too well aware of the loss of quality of life that comes with incurable metastatic cancer, not to mention of the loss of productivity to the community, the increased cost burden on the health system and the effects on carers, family members and the wider community.

 

We disagree with the Draft Guideline which recommends that PSA testing be offered every two years from age 50 to age 69.  There is little evidence to support this proposed protocol.  There are no randomised trials comparing different testing protocols.  The MISCAN modelling referred by the Expert Advisory Panel indicated that annual testing gave an increased benefit which outweighed any additional harm.  

 

In Australia a PSA test is available annually with Medicare subsidy for men between 45 and 74 years of age.  We believe the recommended protocol for PSA testing should be annually and there are important reasons of public health policy supporting annual PSA checks..

Evidence shows that men do not visit a doctor, or get health checks, as often as women.  Public health authorities are endeavouring to get men to have an annual health check.  Together with the other blood tests that are taken as part of an annual health check, a PST test should be included, along with a DRE.

Another reason why we believe that PSA testing should be annually is that an aggressive cancer can develop and become metastatic in less than 2 years.

 

We disagree with the Draft Guideline which recommends that, for men who wish to have regular testing in their 40s, they should be advised that testing begin not earlier than 45 years of age.

 

This recommendation disregards the evidence that early onset prostate cancer has increased significantly and tends to be aggressive and fast-growing.  (see, for example, Salinas CA, Tsodikov A, Ishak-Howard M, Cooney KA. Prostate cancer in young men: an important clinical entity. Published online May 13, 2014. Nat Rev Urol. 2014;11:317-323). 

 

For this reason we suggest that 40 is a more appropriate age for testing to begin. We also agree with the Melbourne Consensus Statement 4 that baseline PSA testing for men in their 40s is useful for predicting the future risk of prostate cancer.

 

We also agree with the Melbourne Consensus Statement 5 that older men in good health with over ten year life expectancy should not be denied PSA testing on the basis of their age.  We consider this Statement to be preferable to the Practice Point about men over 69 years of age in the Draft Guidelines. Increasingly men are living active and healthy lives into their 80s and 90s.

 

Because of the timing of the consultation period (over the busy pre-Christmas season and the summer holiday period), we are unable to provide a more complete submission.  In our opinion, the consultation period has not been adequate, particularly given the lengthy and technical nature of the materials to be considered.

 

End submission

More details for members here:

http://forums.jimjimjimjim.com/index.php?/topic/1103-draft-clinical-practice-guidelines-on-psa-testing/

OR

http://tinyurl.com/paypwy8