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Prostate cancer tests should begin in the forties

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Doubts remain about how frequently men should be tested for prostate cancer despite international consensus that screening should begin when they are in their forties.

The Urological Society of Australia and New Zealand said it agreed with “most of the conclusions” on prostate cancer testing reached by a international panel of experts meeting in Melbourne last week, but warned several key questions remained unresolved.

In a seminal conclusion that is expected to bring to an end years of disagreement, a group of 14 experts attending the Prostate Cancer World Congress 2013 have agreed that all men should have a baseline prostate-specific antigen (PSA) test while in their forties.

The panel said the test would set a baseline, and allow for assessment of the risk of developing prostate cancer later in life.

Those assessed of being at low risk would not need to have follow-up test for at least five years, while those with a PSA above the median for their age would be placed under active surveillance, with test and physical examinations every 12 months.

The panel recommended that men aged between 50 and 69 years undergo a PSA test because of strong evidence it helped in the early detection and treatment of the disease.

Urological Society Vice President Professor Mark Fydenberg said the panel’s conclusions were largely in line with the Society’s recommendations, which were formulated in 2009.

But Professor Frydenberg said there were still unanswered questions regarding the frequency of PSA testing of men of all ages.

He said the Society was contributing to a review of testing guidelines by the National Health and Medical Research Council and Cancer Australia.

“This means that consensus can be built, not only among urologist, but also the non-urological community, so GPs and patients have clear and concise guidelines, and can be reassured they are getting multi-disciplinary agreement about early detection strategies for prostate cancer,” Professor Frydenberg said.

While consensus has been reached about when testing for prostate cancer should begin, American cancer experts have called for a reassessment of the use of the term ‘cancer’ in diagnosis.

The United States National Cancer Institute has raised concerns that many patients suffer unnecessary alarm distress, and undergo unnecessarily aggressive treatment, because they are told they have cancer.

The Institute said many patients with pre-malignant conditions or lesions should not necessarily be told they have cancer, because the problem may not be as serious or urgent as the term suggests.

It cited as an example the strain of breast cancer known as ductal carcinoma in situ, which was slow growing and non-invasive but was often treated as if it were aggressive.

AMA President Dr Steve Hambleton admitted to The Australian Financial Review that using the word cancer when describing a diagnosis often made measured discussion of treatment options difficult.

“When you go to a lady and you say ‘we’ve done a mammogram, turns out you’ve got DCIS’, they say ‘Did you say cancer, doc?’” he said.

“[When] we say we think the best treatment for you is to watch and wait, the person says, ‘You what? You’ve just told me I’ve got cancer and you’re not going to treat me?’

“The challenge here particularly is, do you call it cancer when it’s not going to be progressive and aggressive? Or do you try to identify a characteristic that gives you some guidance on whether you should be treated or not?”

Cancer Council Chief Executive Professor Ian Olver told The Australian Financial Review the best approach may be to strengthen understanding that cancer is a term that encompasses many forms of the disease, rather than try to change the definition of the word cancer itself.

“The real issue is to educate people to understand that cancer is a very general term, and to not always associate it with invasive, highly aggressive disease,” Professor Olver said.

Adrian Rollins

Image by Alex De Carvalho on Flickr, used under Creative Commons licence