Australia and New Zealand have the highest incidence of prostate cancer (PC) worldwide (1, 2). This high prevalence of PC is largely driven by high rates of screening as evidenced by increases in PSA testing leading to large proportion of lower grade tumour detection in younger men(3) and a significant proportion of men over 70 years being screened for PC(4).
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In an era where screening for PC using the PSA test remains highly controversial, the decision on who to screen remains complex. As a general practitioner, who has an established bond by caring for their patients, this decision becomes more difficult and ever so important in managing the disease and patient’s expectations/anxiety. Thus the guidelines by the Australian governing bodies remain a cornerstone in this decision making process. However at the time of this study there were multiple guidelines with significant variations in their recommendations. The USANZ policy in 2009 recommended conducting a single PSA test and DRE at 40 years whilst the college of GP’s did not recommend PSA screening or DRE unless the patient specifically requests it and is clearly counselled(5, 6). Thus the aim of our study was to investigate the trends and variations in current practice in general practice and observe which guidelines are most useful(7).
In the same period, there were a multitude of tests such as the Prostate Health Index etc being introduced in order to compensate for the deficiencies of the PSA test. As such, our secondary aims were to investigate the usefulness of these tests in the primary care setting.
Our results revealed a number of important practical issues in the screening process. We demonstrated a significant discrepancy in PC screening practice between practice settings, with lower rates of screening evident in rural areas. While this could be attributed to poorer survival and mortality outcomes in PC for males living in rural Australia when compared to their urban counterparts(8) the need for better resources and local availability of urology services for appropriate screening and treatment is further highlighted.
In addition, we found that younger GPs tend to conduct more regular PSA testing rather than a digital rectal examination (DRE). While this could be due to a number of reasons, an abnormal DRE is sensitive in detecting PC and when combined with an abnormal serum PSA sensitivity in detection of PC is 95% (9). This suggests the importance of specifically mentioning the role and timing of DRE in the guidelines in conjunction with PSA use.
Our study further revealed that more than 70% of GPs found the USANZ and the College of GPs recommendations were at least ‘somewhat influential’. Thus it is essential that these two bodies in particular collaborate and forming consensus guidelines in PC screening to provide better patient care and have a uniform approach to screen patients.
Our results also identified that a large proportion of GPs believed that active surveillance reduced the PC mortality and were unsure about the effectiveness of external beam radiotherapy in PC and a third of the GPs surveyed did not know the effects of 5-alpha-reductase-inhibitors on a PSA test. Furthermore, tests such as the PHI is not routinely used in the primary care setting and possibly causes more confusion. As such, it is important that these areas are also addressed in future guidelines.
Since the study the National Health and Medical Research Council (10) has published recent guidelines(10). The impact of these guidelines remains to be seen. Until the next gold standard test which can be used for screening in PC, the use of PSA as a screening tool in diagnosis of PC in the asymptomatic man needs more thought.
Weranja Ranasinghe1, Damien Bolton2, Nathan Lawrentschuk2
1 Launceston General Hospital, Launceston, Tasmiania, Australia
2Austin Health, Melbourne, Victoria
1. Ferlay J SH, Bray F, Forman D, Mathers C and Parkin DM. GLOBOCAN 2008, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 10 [Internet]. Lyon, France: International Agency for Research on Cancer; 2010 [cited 2010 July]. Available from: http://globocan.iarc.fr.
2. Cancer survival and prevalence in Australia: period estimates from 1982 to 2010. Australian Institute of Health and Welfare 2012.
3. Ranasinghe WK, Kim SP, Lawrentschuk N, Sengupta S, Hounsome L, Barber J, et al. Population-based analysis of prostate-specific antigen (PSA) screening in younger men (<55 years) in Australia. BJU Int. 2014;113(1):77-83.
4. Litchfield MJ, Cumming RG, Smith DP, Naganathan V, Le Couteur DG, Waite LM, et al. Prostate-specific antigen levels in men aged 70 years and over: findings from the CHAMP study. Med J Aust. 2012;196(6):395-8.
5. Zealand USoAaN. Urological Society of Australia and New Zealand PSA Testing Policy 2009. Urological Society of Australia and New Zealand, 2009.
6. RACGP. Clinical Guidelines [cited 2014 7th June]. Available from: http://www.racgp.org.au/your-practice/guidelines/redbook/early-detection-of-cancers/prostate-cancer/.
7. Ranasinghe WK, Kim SP, Papa NP, Sengupta S, Frydenberg M, Bolton D, et al. Prostate cancer screening in Primary Health Care: the current state of affairs. SpringerPlus. 2015;4:78.
8. Baade PD, Youlden DR, Coory MD, Gardiner RA, Chambers SK. Urban-rural differences in prostate cancer outcomes in Australia: what has changed? Med J Aust. 2011;194(6):293-6.
9. Martinez de Hurtado J, Chechile Toniolo G, Villavicencio Mavrich H. [The digital rectal exam, prostate-specific antigen and transrectal echography in the diagnosis of prostatic cancer]. Arch Esp Urol. 1995;48(3):247-59.
10. NHMRC. Testing for prostate cancer using the prostate specific antigen (PSA) test 2014 [cited 2014 9th July]. Available from: https://www.nhmrc.gov.au/your-health/testing-prostate-cancer.