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PROSTATE cancer kills more than 3000 men in Australia each year, greater than the number of women dying from breast cancer.
Advanced stages of the disease can have a devastating effect on quality of life mainly with spread to bones causing severe pain or spinal cord compression with paraplegia. However, the vast majority of men diagnosed with prostate cancer will die from some unrelated cause.
Attempts to prevent prostate cancer deaths have lead to overzealous attempts to diagnose and treat the disease, resulting in many men receiving unnecessary treatment. Many men also experience surgery complications such as urinary incontinence and erectile dysfunction or radiation treatment complications such as difficulty with urinary or bowel function or bleeding.
Until relatively recently, views have been sharply polarised as either supporting screening using prostate-specific antigen (PSA) testing or not screening at all. The answer for most men almost certainly lies somewhere in between.
Recently, we have seen a significant drift of thought from those who previously favoured mass population screening towards a more moderate approach but those against screening have failed to shift from their steeply dogmatic views.
The Melbourne Consensus Statement (MCS) on testing for prostate cancer was published on line by the BJU International earlier this month.
A series of five statements were formed through the consensus of international experts attending the Prostate Cancer World Congress in Melbourne. The focus is very much on considering an individualised approach to prostate cancer testing rather than mass population screening.
The MCS gives men and their doctors timely access to cutting-edge appraisal of the latest evidence.
Statement 1: “For men aged 50–69, level 1 evidence demonstrates that PSA testing reduces prostate cancer-specific mortality and the incidence of metastatic prostate cancer.” This simply states fact on the basis of large randomised controlled trial evidence. It does make a recommendation for screening but provides factual information that will enable men to make a decision in consultation with their doctors as to whether they will benefit from being tested.
Statement 2: “Prostate cancer diagnosis must be uncoupled from prostate cancer intervention.” Not all men diagnosed with prostate cancer require treatment and many can be managed conservatively by close observation. There is a huge movement towards conservative management by active surveillance and, pleasingly, Australia is leading the way in this area. The argument that a prostate cancer diagnosis invariably progresses to intervention is fallacious and does not represent modern-day practice.
Statement 3: “PSA testing should not be considered on its own, but rather as part of a multivariable approach to early prostate cancer detection.” PSA should not be the only determinant of whether a man elects to be tested or not. Many other factors play a role and, in particular, other elements that may be associated with increased risk such as ethnicity or family history, and elements that might be associated with a man not dying of prostate cancer such as concurrent illness from which the man is more likely to die than prostate cancer. Many tests are emerging that contribute to risk assessment and deciding whether to undergo testing including magnetic resonance imaging scans of the prostate, biomarkers such as prostate cancer antigen 3 and the Prostate Health Index as well as online risk calculators.
Statement 4: “Baseline PSA testing for men in their 40s is useful for predicting the future risk of prostate cancer.” Men in their 40s should be made aware of the value of the PSA test as a risk assessment tool for future prostate cancer risk. It can help triage these men into a more frequent or less frequent PSA testing program. A recent large Swedish study demonstrated that, for many men, a total of three lifetime PSA blood tests could be sufficient. PSA is a poor predictor of current risk of prostate cancer but, in younger men, it is a good predictor of future prostate cancer death. Men should be aware of this information and arrive at their own decisions in consultation with their doctor if they wish to proceed with testing. To deny men participation in such a decision denies an individual right to their own health care management.
Statement 5: “Older men in good health with over ten-year life expectancy should not be denied PSA testing on the basis of their age.” This is largely based on the fact that some older men may have a life expectancy that well exceeds the time frame in which prostate cancer could cause death. The need for this conversation with men over 70 years old should be uncommon.
The MCS has received much media coverage. The “head in the sand” approach of detractors against any form of testing for prostate cancer does nothing to reduce the suffering from advanced prostate cancer and its associated death.
The MCS statements acknowledge and concede that there is a need to be smarter about who ought to be tested for prostate cancer in order to avoid overtreatment and treatment-related side effects.
Professor Henry Woo is an associate professor of surgery at the University of Sydney. On Twitter @DrHWoo. Professor Mark Frydenberg is professor of surgery at Monash University. On Twitter @mfrydenberg
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If the consensus statement are not regarded as guidelines why were they presented to the media as such? I consider it highly irresponsible of those involved in presenting this statement as an end to confusion over PSA testing in their press release. Until this statement is dissected by disinterested experts it remains nothing more than a viewpoint of a group which cannot be considered impartial in making a rational statement on this matter (unlike the USPTF). It is also worth noting only one of the authors was an epidemiologist and even then they could not be considered to not have a conflict of interest.
From the perspective of someone who specialises in data analytics, the opening statement is emotive and actually says nothing – PROSTATE cancer kills more than 3000 men in Australia each year, greater than the number of women dying from breast cancer. This is like comparing apples and oranges. There is no mention of the proportions and numbers of male and female populations and deaths to assess any relativity. You simply can’t make comparisons on the basis of this one statement.
Professors Woo and Frydenberg’s informative summary of the Melbourne Consensus Statement is timely and should be read by all general practitioners as it adds an important update on this frequently contentious topic. In my opinion, PSA testing, coupled with DRE, is the safest way to go as PSA testing results alone can be misleading.
Thanks for comments so far.
To anonymous 1, it is important to recognise that the Melbourne Consensus statements are not guidelines and there is no claim or pretence that they are anything other than the consensus views from experts in the field to assist men wishing to have facts to help guide their individual decision to be tested or not for prostate cancer. Guidelines arise from an organised process with extensive review of the literature and consultation – often a draw back of guidelines is that by the time they are released publicly, they are already out of date or missing crucial latest evidence.
To anonymous 2, those who have been at the extremes against prostate cancer testing have shown little willingness to adjust their position in spite of evidence pointing towards selective benefit. To totally ignore the fact that over 3000 men (more than the number of women with breast cancer) die from the postate cancer each year as well as the countless numbers of men who suffer from the effects of advancing cancer or androgen deprivation therapy is indeed adopting a ‘head in the sand’ approach. Detractors should be challenged to look for middle ground consensus that factors in both the morbidity/mortality concerns associated with prostate cancer as well as identifying strategies to avoid overdiagnosis and overtreatment. One side of the debate appears to be responding and trying to make a difference but it would be refreshing to see the other side of the debate acknowledge the large scale health problem of prostate cancer disease related morbidity and mortality.
I’m fairly sceptical about this. Agreed with the anonymous comment that the phrasing ‘head in the sand’ makes me think that this is one side of the argument trying to gain some ground on the other. This consensus, whilst it might be billed as a step forward, hasn’t really answered the big questions which need to be asked when it comes to PSA screening. It has stated that screening the 50-69 age group will lead to decreased mortality, but hasn’t assessed that against the harms of testing and overtreatment (to be honest this question has already been answered though, and thus I expect that this is the reason why the “consensus” hasn’t addressed it properly). It also hasn’t answered questions on the cost-effectiveness of screening and treatment versus DALYs saved, given that most men die with prostate cancer rather than from it (again, this has been answered in the past, again with an unfavourable result). I tend to think that this consensus is nothing other than a move from one part of the medical profession which has a vested interest in seeing more diagnosis and treatment, to further confuse GPs and other primary care workers on a complex issue.
Reading phrases such as “steeply dogmatic views” and “‘head in the sand’ approaches” as descriptors of the opposing view in the introduction to a statement proporting to involve “consensus” leaves one wondering exactly whose consensus it was.
Until these guidelines are subject to an independent review we shouldn’t get too excited. PSA as ascreening tool is a bit like having a hammer when you really need a screwdriver.
Well said Michael Gliksman !!
A note in passing …..Whoever devised the badly- worded/slanted questions for the vote should re-read the article & re-phrase with application to the statements, please.
This balanced article puts paid to the misandrist pro-breast, anti-prostate screening lobby.