Every few months yet another article on the great big PSA testing controversy appears in the national media.  Should men be tested? Do more men die with, not from, prostate cancer? Does the test do more harm than good? The debate goes on and on.

As good a place to have the conversation as anywhere… Pic: Jay Town

But what about Australian men - how are they supposed to decide what to do when the various medical colleges have radically different points of view? What about their GPs - what advice are they supposed to give to patients who ask about PSA testing?

Apart from a few hot-headed commentators, most experts actually agree about many aspects of testing for prostate cancer. We all agree that prostate cancer is a serious public health issue. Yes, more men will die with prostate cancer than of it, but more than 3,000 men will die from prostate cancer this year – that’s more than the number of women who will die from breast cancer.

It is the second most common cause of cancer deaths in men. That is a fact, as reported by the Australian Institute of Health and Welfare.

We all agree that the PSA, or blood, test is far from perfect, but we also all agree that used in conjunction with the DRE, or physical examination, it is the best test we currently have available. We all agree that testing can lead to overdiagnosis (the detection of cancers that will never be clinically significant during a man’s lifetime). Further, we know that treatment can have very significant negative side effects, including incontinence and sexual dysfunction.

Because of these side effects, or harms, the Royal Australian College of General Practitioners (RACGP) recommends against routine testing for prostate cancer. The reality, however, is that large numbers of men, faced with the seriousness of the disease, do decide to be tested.

The best estimate is that some 20 per cent of men between the ages of 45 and 74 are tested with screening intent every year , which is not dissimilar to rates of participation of eligible women in BreastScreen. PCFA’s research also shows that GPs are the main influencers for men to be tested. Some 46 per cent of men who have been tested report that their GP recommended a test as part of a routine check-up and 15 per cent of men reported that their GP just conducted a test.

So, the great big PSA testing controversy is missing the point. It’s not about whether men should be tested or not, because they are, and will continue to be, tested. PCFA’s research shows that 83 per cent of men aged 40 to 45 expect to be tested at some point in the future. The Australian Health Ministers’ Advisory Council and Cancer Council Australia encourage men to talk to their doctor so that they can make an informed decision about prostate cancer testing.

The conversations may not be perfect, but clearly men are talking to their doctors, and clearly they are being tested in large numbers. Worryingly though, almost 40 per cent of men say the advice about the usefulness of the test is confusing.

So what is the point? The point is that PSA testing is a disorganised mess. There is currently no clear guidance about who might benefit from testing and who would not; no guidance on how frequently men should be tested; and no guidance on what represents a “positive” test result that should be followed up with a prostate biopsy – the only way to diagnose the presence of cancer. In short, there is no guidance on how to maximise the benefits of testing and treatment and minimise the harms.

Collectively, we are doing the Australian community a huge disservice by letting the present situation continue.

That is why PCFA is collaborating with the National Health and Medical Research Council, Cancer Council Australia and the various medical colleges, including RACGP, to develop information and clinical practice guidelines on PSA testing and management of test-detected prostate cancer. Such guidelines, supported by every medical college and all other interested parties, are in the best interests of the Australian Community.

Cancer Council Australia CEO, Prof. Ian Olver, and I are on opposite sides of the great big PSA testing controversy, but we are working together on this important project, which will be a national and international first.

Comments on this post will close at 8pm AEDST.

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27 comments

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    • pa_kelvin says:

      05:07am | 26/11/12

      There’s been a lot of talk this Movember, some good, some not so good. As some –one with Prostate Cancer I read most articles with interest. Movember is not just about men’s physical health, but also supports men’s mental health issues and supports other organisations such as Beyond Blue a men’s help line similar to Helpline or Lifeline.
      I was first diagnosed with Prostate Cancer in November 2007 [age 48] after a routine blood test [not related to any symptoms of any Prostate problems] confirmed a high PSA reading, a further blood test was taken which confirmed the initial high PSA count after which a referral to a Urologist was made. During this appointment a rectal exam [reeeaaalllly uncomfortable] was performed ,at which time I was found to have an enlarged Prostate, further tests involving a biopsy were undertaken the following week ,which confirmed the presence of aggressive Prostate Cancer.
      I sent my GP flowers with a card attached worded   *Thanks to you I’ll be growing Roses, not pushing up Daisys*
      On December 11 th 2007 I had my Prostate removed {Lucky I’m in Private Health] during which I remained in hospital for 6 days [morphine good] until being allowed home ,still with a catheter for a further 2 weeks before having it removed.
      All was good until Feb 2011 until I started having extreme pain in my lower back which was put down to sciatic nerve problems, but which further MRI scans, and a blood-test showed that the Prostate Cancer had Metastasized [transferred] to my bones
      A normal PSA blood count should be below 4, mine at that time was over 1300. Bone scans showed tumours in over 65% of my bones [the only area NOT affected are my legs and arms] ,at which time a course of treatment was started immediately.
      Treatment for Prostate Cancer is undertaken using Hormone therapy consisting of a 4 monthly injection and a daily hormone tablet the major side effects being similar to a woman going thru menopause [hot flushes, sore boobs, irritability etc.].
      Hormone Therapy works to kill the Testosterone. Prostate Cancer feeds of Testosterone, so no testosterone to feed on means a type of remission, but no testosterone no sex life as it’s a chemical castration.   
      Most Radical Prosectomys cause impotence due to nerve damage during surgery .A healthy sex life can still be achieved with the use of Viagra, or similar tablets, or in some cases injections [tried but painful] which can be very frustrating and do lead to a lack of “spontaneity”, but with the Hormone treatment diminishes any desire or urges completely.
      Over time the daily Hormone tablets lose their effectiveness, this could take years, or as in my case 14 months. When monthly PSA checks show a rise the Oncologist takes you of the daily tablet, which then slows the PSA rise….. In my case it hasn’t….
      Recent bone scans have shown no new growths of tumours on my bones , but my PSA levels are still rising , so it looks as if Chemo , for me , will start sooner ,rather than later… not something I’m looking forward to ,and which to be totally honest scares the crap out of me.
      The Prognosis for some-one with my current symptoms 5 years ago would have been a death sentence ,but with new treatments available I should be around for years….This is in part due to funds raised by organisations such as Movember…
      I have good days and bad days, mostly good days with a little bit of discomfort in *hotspots* of my bones, sometimes cant pick-up the grandkids when they visit ,I tire easily and cannot physically handle the workload of my small business that I was doing prior to Feb 2011, which is in itself very frustrating.
      I occasionally break down in tears thinking *what if* and *why me* ,but as I’ve said to family and friends I am not going to lock myself in a dark room and become a complete blubbering mess and I’m determent to be around for a long time yet.
      I have a Loving and supportive wife , 3 daughters and 7 grandkids [6 boys , 1 girl] all of whom are affected by my illness and who all need their Husband , father and grandfather .
      All but 1 of my Grand-children is too young to understand what my condition is, but know Pa isn’t 100%. My daughters like any others with parents going thru what I am wait for the results of my monthly tests, and I know stress as much as I do. My mo website is below to donate.
      http://mobro.co/4851509

    • Mahhrat says:

      07:10am | 26/11/12

      Thank you for sharing this, pa_kelvin.  All the very best mate.

    • Gregg says:

      07:38am | 26/11/12

      You’re not 100% kelvin but 110% plus and I reckon your daughters and grandkids will know it and like I hope there is much more rose growing.
      A saying I once heard was something like it’s not how long one lives but what they put into life and that’s where your 110% comes in.
      All the best.

    • TChong says:

      09:12am | 26/11/12

      pa kelvin
      thanks for the great post.

    • TheRealDave says:

      09:44am | 26/11/12

      Thanks for sharing pa_kelvin. I wish you the best of luck with your future treatments and sincerly hope we see you contributing here for a LOT longer wink

      Its stories like yours that are slowly ‘hitting home’ for me as I turn the big 40 next year and actually start to ‘give a crap’ about my health and long term ‘stick-around-ability’.

    • ByStealth says:

      11:09am | 26/11/12

      As a younger bloke I really appreciate you taking the time to write this up mate. It gives you a fair idea of what could possibly happen and why this is such an important issue.

    • pa_kelvin says:

      03:57pm | 26/11/12

      Thanks to all that read or replied to my Post>>> Friday week I have my next tests, injections and appointment the Oncologist. A decision will be made then as to Chemo, as my last PSA were still climbing.
      Will keep posting and giving updates.

    • acotrel says:

      05:25am | 26/11/12

      If I have cancer, I’d like to be aware of it early, and not left ignorant because of some cost-cutting exercise.

    • marley says:

      07:44am | 26/11/12

      @acotrel - read the article again. It’s not about cost-cutting, it’s about risk management.  You of all people ought to be able to understand what it means if the downside of mass testing is greater than the benefit.

    • Old Fogey says:

      05:30am | 26/11/12

      Being in my mid 60’s and with an enlarged prostate which has been inconveniencing me for years, I really would appreciate a proper set of national guidelines.  In the past I have been sent for PSA tests but have been advised at the time that the test is unreliable.  Why bother?

    • Gregg says:

      07:43am | 26/11/12

      I do not think it is so much that a testing regime is unreliable but my understanding is more so that regular testing will give an indication if any trending commences that would warrant the next step of diagnosis.
      One test alone will not be too meaningful unless you already have a seriously high PSA count.

    • Chris says:

      05:35am | 26/11/12

      What’s PSA?

    • barry from adelaide says:

      08:39am | 26/11/12

      Prostate specific antigen.

    • acotrel says:

      05:45am | 26/11/12

      Collectively, we are doing the Australian community a huge disservice by letting the present situation continue.’

      I hope you are talking about men’s health issues generally ?  I’ve never heard of research into effects of stress caused by bullying and harassment in the workplace and in relationships.  The assessment that heart disease and stroke as a result of high cholesterol might be due to the affects of adrenalin on the liver, rather than poor diet ? Whatr does the NH&MRC; actually do, and who funds it ? What have been it’s recent major achievements ?

    • David V. says:

      06:34am | 26/11/12

      Men’s health gets insufficient attention because of bias against men in the courts and other places.

    • Rosie says:

      07:30am | 26/11/12

      PSA testing is a mess.
      Movember tells men to ask their GPs for a test.
      RACGP says don’t test, unless a man asks to be tested!

    • Gregg says:

      08:18am | 26/11/12

      ” So what is the point? The point is that PSA testing is a disorganised mess. There is currently no clear guidance about who might benefit from testing and who would not; no guidance on how frequently men should be tested; and no guidance on what represents a “positive” test result that should be followed up with a prostate biopsy – the only way to diagnose the presence of cancer. In short, there is no guidance on how to maximise the benefits of testing and treatment and minimise the harms.

      Collectively, we are doing the Australian community a huge disservice by letting the present situation continue. “

      Sometimes you have to make decisions yourself and even then having a bit more help would not go astray.

      I think it was coming up for about five years ago that after continual headaches which I had initially put down to perhaps too long out in the sun and not enough fluids, I eventually went to our local GP and explained the symptons so he organised a scan which initially was alarming in that it showed something of possible significance which was later cleared with a second scan.
      The GP was at least a bit proactive in that he said you’re at the age where we ought to do a full thorough examination as like most blokes when you’re reasonably healthy it is something not too readily thought off and any blood testing etc. had been some years previous so it was early in the year when I had my blood sent off.

      This was where things did go astray for hearing nothing back from the medical centre I assumed all was OK and so on I went with life, still being reasonably active even if finding some things a bit on the tiring side at times, just the weather and getting older I thought.
      Something else I cannot remember came up for me to attend the GP again much later in the year and as would have it he calls up the previous record and says ” Oh yeah, you might be a diabetic ” ( and this from results some nine months previously ) , we better do a blood sugar reading and bloody hell it’s 23! and that’s bloody high with diabetes and normal blood sugars are around 5 and 23 is well on the way to about 33 when you can apparently become comatose!

      So I got injected with something immediately and he put me on to medication to bring the sugar level down fairly rapidly and then it’s a case of reading up on all you ought to do.
      Sugar level is fine these days and all this co-incided some with a local meeting on mens health with concentration on Prostates and we had a guest speaker who had previously been detected early enough and so seeing as I was to go on to having regular roughly six month blood tests because of the diabetes, it was a simple enough decision on my part to add in PSA testing and I actually even add it in myself to the doctors referral for the blood test.

      Touch wood and it is always in the low low end of the readings but like with all they can test for it is the trends to be aware of whilst for now all is pretty well OK on all matters I still keep each regular set of results so I can go back and check for trending if need be and maybe I ought to get smart enough to set up a few graphs for key areas.

      As to who would benefit from regular testing, I would say that anyone where a trend developed would and as in pa_kelvins situation, he may not have had to be reliant on a test he was getting for something else.
      And then as for what would be considered a ” positive ” result warranting further testing/biopsy, kelvin’s doctor was certainly on the ball and quite likely would have been as well if there had been a trend determined.

      There are a lot of medical afflictions that become more dominant with age and regular blood testing, including for PSA is not really a big deal and not all that costly yet it could reveal so much, save many lives and so much in greater costs and grief.

      I fully recommend everyone past 45 start getting regular medical examinations with blood testing included.
      And make sure you follow up because some GPs may not!

    • Rose says:

      08:48am | 26/11/12

      ....“This was where things did go astray for hearing nothing back from the medical centre I assumed all was OK “
      It’s your responsibility to contact the medical centre for your results.

    • Gregg says:

      09:27am | 26/11/12

      There are medical centres where contact is made with patients Rose, especially if they have test results back which indicate something needs to be discussed and that direction needs to come from an alert doctor.

      There are even medical centres where they will contact you every so often to say hey!, it is probably time you saw the doctor again and fortunately I attend one of those now.

    • TheRealDave says:

      10:08am | 26/11/12

      If a Doctor orders Blood Tests for me thent he onus is on him to call me if there is an issue.

      I had a similar story in that I had an issue and went to the Doctors and he ordered some blood tests. After a few weeks I heard nothing back so assumed all was good. About a year later I had an infection from a tooth issue and got some medication and another blood test. Again, heard nothing about it, infection went away. 6 months alter I went in for a checkup before I started playing a full contact sport and I mentioned the previous blood tests and that I never heard anything back. he took more blood and surprise surprise I got a call back in a few days - high cholestoral and can you make a new appointment.

      So, sadly - if you don’t chase them up you won’t know you have a problem. Which I think is absolute bollocks. The doctors don’t need to make the calls if they are far too busy - they have staff that could make the calls, advise results and make followup bookings. Its basic medical care for gods sake. Would take all of about 60 seconds per call.

    • pa_kelvin says:

      03:48pm | 26/11/12

      In my case a follow up appointment was made to see the doctor for the results prior to leaving the surgery, but I had a call from one of the nurses before the next appointment not realising that I was already booked in…..

    • Shane* says:

      08:55am | 26/11/12

      “So, the great big PSA testing controversy is missing the point. It’s not about whether men should be tested or not, because they are, and will continue to be, tested.”

      That’s because you keep telling them to!

      Simple really - The PCFA and Urological Society are the only two organisations who keep this up.

      Mr Lowe, you need to stop telling men they should be tested! It’s half the problem.

      Unfortunately the current mindframe of most men is that they “have” to get tested. Because the DRE made for highbrow comedy gold throughout the last 20 years, the assumption is that we all need to have the test once we hit a certain age. And that’s demonstrably not the case.

    • pa_kelvin says:

      04:13pm | 26/11/12

      Shane* ... see my link above, they have been trialing new test methods, rather than a PSA test.. The article is from 2009 and I have not had time to google for updates to this, but if I do get time and find anything more recent I will link it to you if I see you commenting on the Open Thread… Otherwise I see my Oncologist next week and will ask the question of him.

    • JZR says:

      10:31am | 26/11/12

      Prostate problems are very common but probably not openly discussed because masculinity and sexual potency are threatened. Get checked and if PSA is high discuss the options with your GP. Ask for a referral to a urologist if he or you are concerned. Urologist will assess all the parameters and decide need for further tests or monitoring or biopsy. If biopsy negative monitor situation and consider lifestyle choices. If biopsy positive discuss options, there are many. Negative outcomes of high PSA can be minimized with vigilance and rational choice.

    • Robert S McCormick says:

      02:14pm | 26/11/12

      Just as there is an on-going debate about Climate Change - some scientists say it is real, some say it’s not & others say the jury is still out.
      Is Humankind solely responsible? Are cows & sheep responsible because they fart methane all day, every day? Is it just Nature doing it’s thing? or is it a combination of the lot? The issue has been so politicised no-one is really 100% sure now.
      We can all do our bit to cut down on what we contribute to those emissions & the pollution we strew around without a thought.
      As with Climate Change so too with Prostate Cancer.
      “To do the PSA test or not?” That question has been argued for decades.
      My GP recommends it be done once a year. If the results remain static then we do nothing. If the results show a large change in the figures he recommends it be investigated further. My count, never high, dropped a few points about 5 years ago & since has not remained static ever since.
      Yes, it kills more men per annum than breast cancer does women. The question is, & the stats which should be published, what is the average age of the 3000 men who die of Prostate cancer every year?  What is the average age of the women who die of breast cancer?
      Compared to what Prostate Cancer gets, Breast Cancer gets far more coverage, far more Government Money. Or, at least, that is what we are told.

      There is year-round emphasis on Breat cancer.
      Poor old Prostate Cancer gets the publicity only during November. I worked as a volunteer in a small Sunday Morning Coffee Shop. Ostensibly this was set up to raise funds for Breast Cancer Research. It was staffed by equal numbers of females & males. If it’s not ironic it’s something else for when November came around we males suggested that for the 4/5 Sundays in November the proceeds should be donated to Prostate Cancer Research. That would have left Breast Cancer with getting the cash for the other 48 or more Sundays.
      We got howled down. Why? Aren’t Men’s Health Issues every bit as important as Women’s? That little Coffee Shop was clearing between $100 & $150 every Sunday. We did not think that for it to donate between $400 up to $720 a year to Prostate Cancer was asking too much. Breast Cancer Research would still be getting anything from $4800 up to $7200 per year.
      The result? The men, understandably, stopped volunteering for we believed that we were considered less deserving than the women in the group.
      Our GP says there are, other than genetic reasons, lots of other ones which can possibly lead to Prostate Cancer.
      There are also a number of things we can do to keep that PSA number down.
      Not least of which are:
      (1) Exercise! Yuck? Maybe but try it! It works! You’ll never have that “Body to die for” and it is almost addictive once you get used to going to that gym.
      No time? Most open around 6.00am. What are you doing then? Asleep? It only takes about an hour or even less 3 times a week to strip off a heap of that blubber - the visible stuff & the stuff inside.
      (2) Low-Fat-but-Not-No-Fat” diets.
      (3) Limiting, but not necessarily eliminating, alcohol intake.
      (4)  Weight Reduction - if you can’t see “It” without a mirror or, worse still, reach “It” you need to lose a vat load of lard, boys!!
      (5) Naturally, Tobacco is off the menu!
      JZR, sounds like our GP & if not is a very sensible, intelligent person.

    • pa_kelvin says:

      03:17pm | 26/11/12

      RSMc…. I swear I,m going to take back the $100.oo of pens I bought for Pink Ribbon…..

 

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