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GP guide aims to end prostate confusion

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The number of men undergoing unnecessary prostate cancer tests and procedures is expected to drop following the development of evidence-based clinical guidelines.

In a major step toward resolving decades of confusion and uncertainty regarding the detection and treatment of prostate cancer – the second most common cancer in men – the National Health and Medical Research Council has approved a set of clinical guidelines that can be used by GPs and patients to inform decisions about whether to test for the condition.

The detection and management of prostate cancer has been dogged by controversy amid concerns that shortcomings in the widely-used prostate specific antigen (PSA) blood test has led to over-diagnosis and treatment, leaving many men with serious side-effects including impotence and incontinence.

To cut through the uncertainty and provide clear evidence-based advice to practitioners and patients, Cancer Council Australia and the Prostate Cancer Foundation of Australia (PCFA) undertook a three-year process in which convened representatives from all the disciplines involved in testing, including urologists, pathologists, GPs, radiation and medical oncologists and epidemiologists, to develop consensus guidelines.

The result, PSA Testing and Early Management of Test-detected Prostate Cancer: Guidelines for health professionals, has been approved by the NHMRC as providing evidence-based recommendations for the use of PSA tests and managing patients following a positive reading.

The Cancer Council and PCFA said they hoped the guidelines would help doctors “navigate the daily professional dilemma of informing men about the risks and benefits of testing, and prevent scenarios where PSA tests are conducted without patient consent”.

The test for PSA in the blood is considered an unreliable market of prostate cancer and so it not considered appropriate for use in population screening.

But, in the absence of an effective alternative, many men choose to have it anyway.

The problem is that false-positives can lead to a patient having an invasive biopsy procedure, exposing them to the risk of serious side-effects.

The NHMRC estimates that for every 1000 men aged 60 (and who do not have an immediate relative with prostate cancer) who take the test annually for 10 years, two will avoid a prostate cancer death before 85 years.

But a further 87 will, as a result of a false-positive test, have an unnecessary biopsy. As a result of the biopsy, 28 will experience side-effects including impotence and incontinence, and one will be hospitalised.

The risk of a false-positive and the attendant unnecessary yet serious complications means that the decision to have a PSA test is not a straightforward one, and PCFA Chief Executive Officer Associate Professor Anthony Lowe said the new guidelines were intended to help doctors and patients navigate the decision to maximise the benefits of the test and minimise the harms.

“Contention about the PSA test has made it difficult for health professionals to take a consistent, evidence-based approach to the test,” A/Professor Lowe said. “While the debate has played out, thousands of men have continued to take the test, as it’s the only available biomarker to assist doctors in assessing a man’s prostate cancer risk.”

Cancer Council Chief Executive Officer Professor Sanchia Aranda said use of the guidelines should result in less over-treatment associated with PSA testing.

“The PSA test is an imprecise test, and has the potential harms as well as benefits,” Professor Aranda said. “Use of the guidelines will hopefully reduce the level of over-treatment and guide improved management of men with early stage prostate cancer until we have a better biomarker.”

Among other advice, the guidelines recommend:

  • an end to rectal examination of asymptomatic men by GPs;
  • no PSA test for men unlikely to live another seven years because of other health complaints;
  • harms of PSA tests may outweigh potential benefits for men older than 70 years; and
  • for men aged 50 to 69 years who decided to have PSA testing, tests should be conducted every two years, not annually.

 The guidelines can be downloaded from: www.pcfa.org.au and wiki.cancer.org.au/PSAguidelines

Adrian Rollins

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