more_vert
SINCE the beginning of the first COVID-19 pandemic, many patients have missed health care appointments and pathology tests, and this is not good news for preventive health, early detection, and fast access to treatment.
Cancer Australia reported a 10% drop in prostate-specific antigen (PSA) testing from January to September 2020 due to the impact of COVID-19. Given the most recent lockdowns affecting a significant proportion of the Australian population, we can expect similar declines in PSA testing until at least the end of 2021.
We are seeing increasing pressure and ongoing postponement of elective surgeries in hospitals across the country, even in states not currently experiencing COVID-19 outbreaks.
In this environment, any tools we have for prevention and early detection should be used to the fullest extent right now to mitigate the risk of hospitals being overwhelmed and patients missing out on care. Hospitalisations and cost of care are much greater in men with advanced and metastatic prostate cancer compared with early, localised disease, so it makes sense financially to diagnose early and implement appropriate management strategies including surveillance, surgery and radiation therapy.
Australia has among the highest rates of prostate cancer in the world. That is why we should be making the case even more strongly for screening. We need to give clinicians the tools to confidently discuss PSA testing with their patients, and urge those who have missed tests in the past 18 months to catch up.
While we grapple with the current COVID-19 outbreaks and vaccine rollout, it is easy to take our eye off the ball when it comes to other areas of health. But in the area of prostate cancer, we have made such good progress in recent years it would be a tragedy to let this happen.
In Australia, it’s fair to say that we are close to gold standard when it comes to diagnosing and treating prostate cancer. We’ve led the world in providing widespread access to PSA screening, and have seen appropriate uptake of multiparametric magnetic resonance imaging (MRI) to assist with targeting biopsies (based on Medicare data about Medicare Benefits Schedule [MBS] item number 63541).
We are lucky that we have had the support of government with respect to MBS funding for multiparametric MRIs and transperineal biopsies to support this high standard of care. We now have an even higher level of accuracy in diagnosis and urologists can confidently offer the option of active surveillance for men with low risk cancers.
In fact, the Prostate Cancer Outcomes Registry for Australian and New Zealand men annual report 2020 showed that 71% of men with low risk prostate cancer now opt for active surveillance or watchful waiting, a figure that has increased significantly from just 54% in 2015. This reduces the risk of overtreatment of non-aggressive prostate cancers.
Surgery among men with low risk disease declined from 39% to 24% between 2015 and 2018, and for patients who choose surgery, robotic radical prostatectomies are now much more accessible.
However, all of this progress is at risk if we don’t take action on the PSA test guidelines. These must be reviewed and the appropriate accompanying communication strategies rolled out for GPs as well as patients in order to ensure that we are using the test to provide the most benefit for patients, based on the latest evidence and practice.
When the 2016 guidelines were written, the data they were based on was already 7–8 years old. The screening data from the large European studies have matured enormously, and there is now evidence to show the benefit of using the PSA test to screen selected asymptomatic men. The use of multiparametric MRIs to follow up on high PSA results is not yet included in the guidelines, and there is a persistent misconception about the risk of unnecessary biopsies and surgeries.
Recent consumer survey results from the Prostate Cancer Foundation of Australia showed that 70% of men did not know the symptoms and 67% of men reported unmet needs for information on prostate cancer before their diagnosis, saying they wished they had known more about it. Patients need education not only to prompt informed discussion with their GP about screening, but also to be aware of what results could mean for them and their families, and what happens next if a PSA result is high.
Another major element of the guidelines which requires a rethink is the age bracket in which asymptomatic testing is recommended, in particular the idea that we should not begin screening for a man who is over the age of 69 years.
In Australia, 70 years is no longer considered old by most of us who are middle aged or above. The advice to screen should be based on the likelihood of survival for men who are well, have few comorbidities, and are likely to live for several years into the future, rather than an age cut-off with limited real-life relevance.
Moreover, screening older men to facilitate early diagnosis and keep them out of hospital should be even more of a priority now given our overloaded hospitals and exhausted medical staff.
A recent poll by InSight+ also saw a majority of respondents supporting an urgent update to the guidelines.
Reducing the risk of harm is at the centre of what we do as clinicians, and as such it is worth remembering that a cancer diagnosis affects more than just a single patient.
A cancer diagnosis is devastating at the best of times for any family. Earlier detection at least gives us the chance to spare families a diagnosis of metastatic prostate cancer, especially during the COVID-19 pandemic, with the added stress of separation from loved ones, financial worries, and concerns about navigating COVID-19 risk and border closures to safely access health care.
Even diagnosing a cancer at a point where a patient has no chance of cure but the option to extend their life and reduce impending symptoms has beneficial impacts for the patient and their loved ones, allowing them time to come to terms with the prognosis and to make the most of the time they have left.
With the right approach we can reduce the burden of prostate cancer on individuals, families and the health system. This includes managing how we communicate with patients about screening and the discovery of low risk cancers where active surveillance may be the best option.
The opportunity is there to become the world leader in this space and to ease some of the pressure on our hospitals and health system. Most importantly this is a chance to save men’s lives, and to save thousands of families the pain of an advanced cancer diagnosis. This is a chance we should not waste.
Dr Peter Heathcote is a urologist with special interests in cancer of the prostate, pelvic oncology, and robotic surgery, and is an Adjunct Professor with the Australian Prostate Cancer Research Centre Queensland. He is a former President of the Urological Society of Australia and New Zealand and an Examiner in Urology for the Royal Australasian College of Surgeons.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.
Loading ...
I would like to stress to all men not to rely on PSA test alone, it is a must to be examined by digit. Some doctors will not preform a digital exam and rely on PSA which could be very risky.
It would be good to ascertain unbiased screening information. At last count the BMJ cane down on the side of no screening back in 2018.
Prostate screening is a very long way behind cervical screening using CST.
Couldn’t agree more. I never understood why the powers that be made such a big deal of the dangers of over-diagnosis and the treatment thereof. It was always exaggerated. The PSA is far from perfect, but still the best screening test we have, and which is actually quite cheap and easy to do – just throw it in as part of the general blood screen on anyone over 45. Do it annually for those over 60, and be guided by any upward trend, with a mpMRI when it looks suspicious.
My major disappointment was when they finally brought in the Medicare item (belatedly) for the mpMRI, then typically limited its ordering to specialists – ie those who already have a vested interest in intervention – when doing the MRI before referring to the specialist level would have provided an opportunity for the best approach for the individual patient to be decided upon.
Sadly, I think it is still true that most (not all) urologists thing first of surgery, when there are often better alternatives. That is the area that needs the most review now, I feel. So the patient is given all the options before coming under any pressure to take up and specific option.
The RACGP needs to help mitigate confusion over PSA testing. On one hand they were participants and signatories to the national guidelines on PSA testing but in the other hand they advise against PSA testing in their Red Book guidance. No wonder GP’s are confused.