[Department of Error] Department of Error

Unfinished business: women’s health inequality in the USA. Lancet 2016; 388: 842—In this Editorial, the name of the organisation responsible for the report into women’s health-care cover should be the “National Women’s Law Center (NWLC)”. This correction has been made to the online version as of Sept 1, 2016.

New prostate cancer guidelines endorsed by RACGP

Evidence-based guidelines launched earlier this year for using the prostate specific antigen (PSA) blood test to assess prostate cancer risk in patients have been endorsed by the Royal Australian College of General Practitioners.

The PSA Testing and Early Management of Test-detected Prostate Cancer: Guidelines for health professionals were developed in partnership with the Prostate Cancer Foundation of Australia (PCFA) and Cancer Council Australia and were approved by the National Health and Medical Research Council (NHMRC).

The guidelines align with the RACGP view that using either the PSA test or a digital rectal examination is unreliable and not recommended.

According to RACGP President Dr Frank R Jones: “The best way to approach prostate health is for the patient to discuss his concerns with his general practitioner who after careful deliberation, will determine the need for testing or not. In the vast majority of cases it is unnecessary.”

Evidence has found the harm of a false positive outweighs the possible benefit. For every 1000 men aged 55-65 who had an annual PSA screening test, 87 will find out through an invasive biopsy that they have received a false positive. 4 of the 1000 men screened will eventually die of prostate cancer and only one man will be saved through PSA testing.

The new guidelines include:

Men considering a PSA should be given information about the benefits and harms of testing.
Men with an average risk who have decided to undergo regular testing after being informed of the benefits and harms should be offered PSA testing every 2 years from age 50-69. If the total PSA concentration is greater than 3ng/mL then further investigation should be offered.
Men over 70 who have been informed of the benefits and harms of testing and who wish to start or continue regular testing should be informed that the harms of PSA testing may be greater than the benefits of testing in their age group.
Men with a father or one brother who has been diagnosed with prostate cancer has 2.5 – 3 times higher than average risk of developing the disease. If these men have decided to undergo regular testing after being informed of the benefits and harms, they should be offered PSA testing every 2 years from age 45 to 69.
Men with a father and two or more brothers who have been diagnosed with prostate cancer have at least 9 to 10 times higher than average risk of developing the disease. If these men have decided to undergo regular testing after being informed of the benefits and harms, they should be offered PSA testing every 2 years from age 40 to 69.
In a primary care setting, digital rectal examination is not recommended for asymptomatic men in addition to PSA testing however this may be an important assessment procedure if referred to a urologist or other specialist for further investigation.
Mortality benefit due to an early diagnosis of prostate cancer due to PSA testing isn’t seen within less than 6-7 years of testing so PSA testing isn’t recommended for men who are unlikely to live another 7 years (subject to health status).
A PSA testing decision aid for men and their doctors is under development by PCFA and Cancer Council Australia.

Other recommendations also include further investigations if the PSA concentration is above 3 ng/mL; prostate biopsy and multiparametric MRI; active surveillance and watchful waiting.

PSA Testing and Early Management of Test-detected Prostate Cancer: A guideline for health professionals is available for download at www.pcfa.org.au and wiki.cancer.org.au/PSAguidelines.

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[Correspondence] The urgency of a sociocultural approach to adolescent men’s health risk behaviours

Adolescent men’s health is a global concern.1 Most reports and consensus focus on individuals’ health risk behaviours—eg, tobacco consumption, binge drinking, and drug consumption, among others.2 In addition to this approach, we need to incorporate a sociocultural dimension into adolescent men’s health.

New prostate cancer clinical guidelines launched

Australian health professionals will now have access to evidence-based recommendations for using the prostate specific antigen (PSA) blood test to assess prostate cancer risk in patients.

The PSA Testing and Early Management of Test-detected Prostate Cancer: Guidelines for health professionals were developed in partnership with the Prostate Cancer Foundation of Australia (PCFA) and Cancer Council Australia and have now been approved by the National Health and Medical Research Council (NHMRC).

PCFA Chief Executive Officer, Associate Professor Anthony Lowe said contention about the PSA test has made it difficult for health professionals to take a consistent, evidence based approach to the test.

“The guidelines cut through the contention and provide guidance in relation to an individual man’s circumstances and on how to manage a patient if he requests and consents to taking the test,” he said.

The recommendations include:

Men considering a PSA should be given information about the benefits and harms of testing.
Men with an average risk who have decided to undergo regular testing after being informed of the benefits and harms should be offered PSA testing every 2 years from age 50-69. If the total PSA concentration is greater than 3ng/mL then further investigation should be offered.
Men over 70 who have been informed of the benefits and harms of testing and who wish to start or continue regular testing should be informed that the harms of PSA testing may be greater than the benefits of testing in their age group.
Men with a father or one brother who has been diagnosed with prostate cancer has 2.5 – 3 times higher than average risk of developing the disease. If these men have decided to undergo regular testing after being informed of the benefits and harms, they should be offered PSA testing every 2 years from age 45 to 69.
Men with a father and two or more brothers who have been diagnosed with prostate cancer have at least 9 to 10 times higher than average risk of developing the disease. If these men have decided to undergo regular testing after being informed of the benefits and harms, they should be offered PSA testing every 2 years from age 40 to 69.
In a primary care setting, digital rectal examination is not recommended for asymptomatic men in addition to PSA testing however this may be an important assessment procedure if referred to a urologist or other specialist for further investigation.
Mortality benefit due to an early diagnosis of prostate cancer due to PSA testing isn’t seen within less than 6-7 years of testing so PSA testing isn’t recommended for men who are unlikely to live another 7 years (subject to health status).
A PSA testing decision aid for men and their doctors is under development by PCFA and Cancer Council Australia.

Other recommendations also include further investigations if the PSA concentration is above 3 ng/mL; prostate biopsy and multiparametric MRI; active surveillance and watchful waiting.

The report says there is no evidence to support a national PSA screening program to all men of a certain age group.

Cancer Council Australia CEO, Professor Sanchia Aranda says use of the guidelines will hopefully reduce the level of over-treatment.

“The NHMRC’s Information Document for health professionals, recommended as a companion document to the guidelines, estimates that for every 1000 men aged 60 with no first degree relatives affected by prostate cancer who take the test annually for ten years, two will avoid a prostate cancer death before the age of 85 as a result. Yet 87 men will receive a false-positive PSA test result and have an invasive biopsy that they didn’t require –28 will experience side-effects, including impotence and incontinence, as a result of this biopsy, and one will require hospitalisation.”

PSA Testing and Early Management of Test-detected Prostate Cancer: A guideline for health professionals is available for download at www.pcfa.org.au and wiki.cancer.org.au/PSAguidelines.

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Low stress resistance leads to type 2 diabetes: study

A recent study published in Diabetologia (the journal of the European Association for the Study of Diabetes) has found 18-year-old men with low stress resistance have a 50% higher risk of developing type 2 diabetes in their lifetime.

The population based study examined all 1,534,425 military conscripts in Sweden during 1969–1997 who underwent psychological assessment to determine stress resilience. They had to have had no previous diagnosis of diabetes.

They were followed up for type 2 diabetes from 1987–2012 with the maximum attained age being 62.

After adjusting for body mass index, family history of diabetes, and individual and neighbourhood socioeconomic factors, the research found 34,008 men had been diagnosed with type 2 diabetes.

The study found the 20% of men with the lowest resistance for stress were 51% more likely to have been diagnosed with diabetes than the 20% with the highest resistance to stress.

Authors Dr Casey Crump, Department of Medicine, Stanford University, Stanford, CA, USA, and colleagues in Sweden and the USA admit lifestyle behaviours related to stress including smoking, unhealthy diet and lack of physical activity could be related to the increased risk of diabetes. The study also could not make any assertions about women as it only included male army cadets.

The authors conclude: “These findings suggest that psychosocial function and ability to cope with stress may play an important long-term role in aetiological pathways for type 2 diabetes. Additional studies will be needed to elucidate the specific underlying causal factors, which may help inform more effective preventive interventions across the lifespan.”

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[The Lancet Commissions] Women and Health: the key for sustainable development

Girls’ and women’s health is in transition and, although some aspects of it have improved substantially in the past few decades, there are still important unmet needs. Population ageing and transformations in the social determinants of health have increased the coexistence of disease burdens related to reproductive health, nutrition, and infections, and the emerging epidemic of chronic and non-communicable diseases (NCDs). Simultaneously, worldwide priorities in women’s health have themselves been changing from a narrow focus on maternal and child health to the broader framework of sexual and reproductive health and to the encompassing concept of women’s health, which is founded on a life-course approach.

[Perspectives] Ana Langer: global leader in women’s health

Ana Langer, leader of the Women and Health Initiative (W&HI) at the Harvard T H Chan School of Public Health, is the first to admit that there have been major advances in women’s health in the past decade, notably in maternal and reproductive health. But she is also clear about what she calls “the unfinished agenda of women’s health”. That agenda is powerfully articulated in the Lancet Commission on Women and Health, of which Langer is the lead author. “A key question the Commission seeks to address is why health systems are repeatedly failing women when women are the main users of, and providers of, health care”, she says.

[Comment] Valuing the health and contribution of women is central to global development

During my mother’s four pregnancies, her health was viewed as a way to improve the wellbeing of her children. Between the time that my mother had her children and I had mine, more attention was paid to the health of women themselves—and particularly their survival. This concern with maternal health and survival, especially for women in low-income countries, led to the launch of the Safe Motherhood Initiative in 1987, the first global effort to focus the world’s attention on maternal health. Since then, women’s health has expanded to encompass sexual and reproductive health and, more recently, the complex interplay of factors throughout the life course, which are explored in the Lancet Commission on Women and Health.

[Comment] Making women count

Women and health, not women’s health. The distinction is important. It is important because unless the contribution women make to society is recognised, the new post-2015 global goal of sustainability will be little more than a distant utopia. The idea of women and health therefore carries some urgency. The reproductive rights of women are too often marginalised in global health, especially the rights and needs of adolescent girls and older women. But the argument of this Lancet Commission on Women and Health1 is that the global health and development community needs to go beyond sexual and reproductive health and rights.

[Correspondence] Hormone therapy and ovarian cancer

Menopausal hormone therapy has played an important part in women’s health care for decades, for millions of women. These women and the regulating agencies are very sensitive to possible adverse effects. Therefore, it is necessary to assure the validity of hormone therapy pharmacovigilance.