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Advice to dump prostate test could ‘cost lives’

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Australian specialists have launched a rare broadside at their Canadian colleagues over suggestions that a widely used test for prostate cancer should be dropped.

As public consultations on new national draft prostate cancer testing guidelines is about to commence, the Urological Society of Australia and New Zealand has warned that revised Canadian guidelines issued late last month could “ultimately cost lives”.

The Canadian Task Force on Preventive Health Care, in a report published in the Canadian Medical Association Journal, concluded that the “available evidence does not conclusively show that PSA [Prostate Specific Antigen] screening will reduce prostate cancer mortality, but it clearly shows an elevated risk of harm”.

The recommendation has come amid claims that PSA screening has led to over-diagnosis of prostate cancer, causing many men to undergo biopsies and other procedures that can have serious side effects, including incontinence.

But Urological Society President-elect Professor Mark Frydenberg said the Society rejected the Canadian Task Force’s interpretation of the data.

“While we acknowledge there have been issues with over-diagnosis of prostate cancer in the past, we believe these recommendations go too far and may lead to delayed diagnosis and increased mortality,” Professor Frydenberg said.

He said that although the PSA blood test was “imperfect, it still remains the best chance of catching prostate cancer in time, and long-term international studies confirm that this simple blood test can reduce the risk of prostate cancer deaths by 21 per cent”.

Professor Frydenberg said the Canadian interpretation did not take into account recent improvements in surgical techniques, nor the fact that 45-year-old men with a PSA level in the top 5 to 10 per cent comprised 50 per cent of subsequent prostate cancer fatalities – making them the ideal group to test.

“We don’t want to return to the old days when men suffered and died unnecessarily, but we need to be smarter about how we use the test so that men are not harmed by unnecessary interventions,” he said, adding that urologists sought to tailor treatment to eliminate unnecessary procedures.

Associate Professor Shomik Sengupta, of the Society’s Genitourinary Oncology Special Advisory Group, said new diagnostic tools, such as multiparametric MRI scans, were being used to help rule out cancer in men with elevated PSA, helping reduce the number of biopsies, while improved techniques reduced the chances of complications like infection when biopsies were required.

In addition, Professor Sengupta said, where a cancer is found to be of low risk, it is often managed through active surveillance rather than surgery.

He said currently 36 per cent of Australian men with low risk prostate cancer were subject to active surveillance, with little to no impact on their quality of life.

“[The Society] is concerned the Canadian publication appears to place greater emphasis on the potential risk and harms of PSA testing, based on low-level evidence, than on the potential benefits based on stronger evidence,” Professor Sengupta said.

New draft guidelines on prostate cancer testing are due to be released by the National Health and Medical Research Council for public consultation on 4 December.

Adrian Rollins