Yes finger, No finger

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.

Whom to believe and what to do?

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.

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

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…..