Getting to the bottom of the Great PSA Controversy
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.
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.
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