Tag Archives: cancer

Yes finger, No finger

4 Dec

One of our favourite sports is commenting on the frequent updated guidelines on prostate cancer testing. Currently there are SEVEN approved sets of guidelines – each of which differs from the others on who and how to test men without symptoms to see if they have cancer (screening).

Today, there is an eighth.

To be fair, the new guidelines are in draft form only, they aim to bring consensus to the process and they are looking at the evidence as carefully as one can.

The most interesting early discussion point is that digital rectal examination (DRE – the finger up the backside) is no longer recommended. This comes as a surprise to those of us who were taught that DRE is free, simple, side effect free and useful. But the best research study suggests that it only picks up a very, very small number of additional cancers and runs the risk on increasing the false positive rate (suggesting men have cancer and need biopsies when in fact there is nothing wrong).

The jury is still out on this and the guidelines are only in draft stage. But at least you can have some expert advice to back you up when you are arguing with your doctor about the merits of DRE!

See http://wiki.cancer.org.au/australia/Guidelines:PSA_Testing/Role_of_digital_rectal_examination for more details.

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When a cancer’s not a cancer

12 Dec

A fascinating article on the website The Conversation discusses whether we should abandon the word “cancer”. Why? Because so many cancers these days are so minor that they won’t ever cause any harm to the patient. But the very act of using the word cancer can frighten people well out of proportion to the danger they face.

This is particularly so for cancers which are found by screening tests. The theory is that finding a cancer in the early stages improves the odds of survival. The best known examples are prostate and breast cancer.

Yet interestingly, after 30 years of screening for breast cancer in the USA, the number of minor cancers detected has doubled … but the number of advanced cancers detected has dropped by less than 10%. In other words, lots of new cancers are being found, but they were unlikely to ever cause any problems even if not discovered. The same applies – perhaps more so – to prostate cancer.

These extra “cancers” also make the figures for treatment look much better. If you “treat” all cancers – including those that aren’t nasty – your survival figures will dramatically improve.

The discussion around renaming these early or minor cancers is part of a movement in medicine against over-diagnosis and over-treatment. Doctors and patients both have a role to play – doctors need to think more clearly about the implications of conditions, and patients need to understand that medicine is not perfect, that we are always learning and re-evaluating our knowledge; and that doing more can be worse than doing less.

Whom to believe and what to do?

10 Aug

Readers of our blog will know that one of our favourite sports is to report on every new set of PSA testing guidelines that come our way, if only to show how often they change and contradict each other.

Poking fun at PSA is just too easy. This week two major recommendations regarding the pros and cons of PSA testing were released within 48 hours of each other. And as expected – they contradict each other completely.

The Prostate Cancer World Congress met in Melbourne and released a consensus statement regarding testing. This is the expert opinion from world leaders in the field – primarily urologists. The main points they made were:

– Prostate cancer testing is a separate issue from prostate cancer treatment (finding prostate cancer early does not have to involve surgery. Depending on the PSA and then other tests, it could involve just watching to see how quickly everything develops/evolves.)

– A man in his 40s can have a baseline test to determine future risk.

– For men between 50 and 70, regular PSA reduces the risk of prostate cancer spreading by 30% and decreases the risk of dying by 20%. Older men who are expected to live at least 10 more years will probably also benefit from testing.

Fair enough. The experts have spoken and the logic seems reasonable.

But wait! A couple of days later the Australian National Health and Medical Research Council – the chief scientific research body released its recommendations for PSA testing based on a review of the world research and literature. Their advice is that PSA testing has no discernible impact on the risk of dying of prostate cancer but runs a significant risk of leading to overdiagnosis and overtreatment including significant side effects.

The key points they make are:

If 1000 60-year-old men who have a low-risk of prostate cancer get tested annually for 10 years then:
• Two will avoid dying of prostate cancer before age 85.
• 28 will be diagnosed with prostate cancer as a result of the PSA testing, but many of them would never have has symptoms so their test is finding a disease that actually doesn’t matter
• 87 will undergo unnecessary biopsies and 24 will suffer significant side effects as a result.
• 25 will undergo potentially unnecessary treatment, 7-10 of whom will be left impotent or incontinent as a result.

The full NHMRC report can be read at http://consultations.nhmrc.gov.au/files/consultations/drafts/resources/men4apsatestingreportv03190713.pdf

So there we have it – the latest evidence analysed by up to date experts resulting in completely contradictory advice.

What is a patient to do? What, for that matter, is a GP to do?

The truth is – we’re not sure. By all means, talk to your doctor. And we will do our best to tease out the evidence and discuss the pros and cons with you. But don’t expect us to give a clear-cut answer or definitive advice.

We’re not expert enough to do that.

Difficult decisions

10 Jun

The Angelina Jolie story has done its time in the news cycle and as the water cooler conversation of the week – and rightly so. The decision to undertake any form of surgery isn’t easy. To do so as prophylaxis (preventative medicine), even harder. To do so with body parts that carry an emotional weight beyond their physical significance, hardest of all.

There aren’t many body parts that we consider removing “just in case”. Appendices (appendixes for our American readers) are usually left alone – though there is discussion about prophylactic surgery for those going on Winter expeditions to Antarctica where evacuation isn’t easy. Thirty years ago if one child in the family had their tonsils out, it seemed sensible to remove them from all the siblings as well. And in the circumcision war debates, prevention of penile cancer, HIV and partners cervical cancer are now rolled out as arguments by those in favour of the procedure.

The Angelina Jolie case is grounded in a bit more fact than most of these discussions, largely because her genetic profile made the statistics easy to analyse. The BRCA1 and BRCA2 genes are now well quantified as risk factors. As our regular readers know, we think there is a lot of misuse of data in the medical world, but from what we’ve read Ms Jolie’s assessment of her own risks seemed pretty accurate. It raises the question who else should have a prophylactic mastectomy.

Our general approach – and the discussions would vary enormously from patient to patient – is that if you have a first degree relative (parent, sibling or child) with breast cancer we’d discuss how to measure your risk more carefully and if you had 2 or more first degree relatives or several second degree relatives (aunts, cousins etc), it may be worth talking to a familial cancer or genetics clinic. Our doctors are happy to guide you through the process and refer you to the appropriate people.

One interesting story that crossed our desk is that of a male who has requested a prophylactic prostatectomy because of his genetic profile. The gentleman was 53yrs old, had a normal PSA test but did have a strong family history of prostate cancer and was shown to have microscopic dots of cancer in his prostate when he had a biopsy. (How he managed to convince doctors to perform a biopsy when he had no symptoms and a normal PSA is not clear!)
His surgeons reportedly said that whilst it was not usual to remove a prostate in men without problems, the risk of BRCA +ve men developing metastatic prostate cancer is three times the risk of other men. On that basis plus the known small focii of cancer, surgery was agreed to.

The implication however is controversial. How much risk is too much? Would you have a mastectomy if you knew you had a 50% chance of cancer? What about 10%? What about 1%? Would you want your prostate out – risking impotence, incontinence and the risk of infection – if you knew that your risk of getting prostate cancer (which might be treatable anyway) was 5%, 25%, 75% ?

Another issue is ethical. If you have cancer – you have no obligation to ring your cousins and tell them. If you know you have a cancer gene – and therefore maybe so do they – are you morally obliged to let them know, even if it compromises your own right to privacy?

Over the past hundred years, the two big changes in medicine have been the development of anaesthesia and antibiotics, which between them have completely changed the way medicine in practiced. It seems pretty clear that the biggest change in medicine over the next fifty years will be development of medicine tailored to everyone’s individual genetic profile. Such knowledge will provide valuable information – but it might make some decisions even more difficult!

If it’s Wednesday there must be new guidelines….

1 May

Once upon a time doctors were encouraged to use their own judgement. Now we are encouraged to follow guidelines (though they are really just somebody else’s judgement about what is best for the population as a whole, not specifically targeted at the patient sitting in front of us, and certainly not as immutable as the 10 Commandments).

So it’s pretty confusing for patients – and highly confusing for doctors – to realise that there are currently – count them – seven sets of “official” guidelines in Australia for what is best practice in testing for prostate cancer. And they all differ. It would be nice if the learned Colleges of Pathology, Surgery, General Practice, the NHMRC, Medicare etc could agree.

Let’s add one more to the list. A new study from Sweden (www.bmj.com/content/346/bmj.f2023) suggests that men should only be tested three times in their lives – around the ages of 45, early 50s and age 60. If each of those tests is normal, their lifetime risk of prostate cancer is very low. If any of the tests is above average, then testing more often is called for.

The theory (and evidence) is reasonably good. Whether this recommendation will be adopted by all the experts remains to be seen. And sometime in the next week or two, you can expect a new set of guidelines to be released…..

Needles flying everywhere Part 2

22 Feb

Gardasil has been one of the great immunisation success stories of the past decade. The vaccine, which prevents HPV (human papilloma virus = wart virus) is given to teenage girls and decreases their risk of developing genital warts in general and decreases the risk of cancer of the cervix. Whilst it doesn’t completely eliminate the need for pap smears or provide 100% protection, it’s certainly quite effective.

Now Gardasil is available to boys. Wart virus can certainly affect both sexes and HPV can also cause cancer in men, particularly cancer of the penis and in some cases cancer of the anus. Boys who contract HPV can also transmit it to their partners, increasing the risk that they will develop disease or cancer.

The national Gardasil program for boys is being rolled out over the next two years.

In 2013 and 2014 all boys in Year 7 AND Year 9 will be offered the vaccine. (Boys in Year 8 this year will get next year in year 9.)  After that it will just be available to boys in Year 7. 

Unfortunately there is no government funded catchup program for boys already in Year 10 and beyond, though we can arrange private stock.

The vaccine involves three injections over a six month period. Whilst it can be given at school, we have vaccines available at the surgery and therefore we are able to administer the vaccine here if you prefer. Please discuss with reception and make an appointment.

 

Statistically it’s much better when it’s exactly the same

28 Jan

It’s very easy to get confused over prostate cancer screening – doctors do it all the time! Currently in Australia there are SEVEN distinct “official” recommendations regarding who should be screened for prostate cancer and how often.  It’s no wonder nobody actually knows what to do.

The big debate of course, is whether prostate cancer screening should be done at all.  Both sides of the debate present statistics, and they can be twisted to defend any position at all.

Here is a great example we came across.

FACT – Survival rates for prostate cancer in America are about 80%.   In England 43%.

FACT – the chance of dying of prostate cancer in America is virtually identical to the chance in England.

OK….how do we reconcile those two completely true, but apparently contradictory, facts?

Here’s how.

Americans love screening and they test lots of people for prostate cancer very often.

And they love treating prostate cancer, no matter how early they find it.

So in America – 136 out of 100,000 men are found each year to have prostate cancer. You can bet nearly all get some sort of treatment.

In England, where many fewer men are screened, only 49 out of 100,000 men are diagnosed.

Now, if all prostate cancers mattered, you would think that the diagnosis in lots of men in England is being missed, that their treatment is being delayed and that they will die as a result.
But the rate of death from prostate cancer in England is 28 per 100,000 men per year.  In America, its trivially better at 26 per 100,000.

In other words, your chance of being TOLD you have prostate cancer in America is more than double in England (136 vs 49).  But your chance of DYING of prostate cancer is basically the same (26 vs 28).

Since more men are diagnosed and treated in America, it looks like regular screening, early diagnosis and aggressive treament is more effective, even when the end-results are the same.

The conclusion?  Research statistics are very dangerous creatures and need to be handled with care.  Talk to your GP about YOUR personal risk.