Canadian Prostate Cancer testing guidelines’ conclusions questioned

New Canadian guidelines on prostate cancer testing that recommend against use of the PSA blood test could, if followed by practitioners and men, ultimately cost lives, according the Urological Society of Australia and New Zealand.

In the Canadian Medical Association Journal, the Canadian Task Force on Preventive Health Care concluded that “available evidence does not conclusively show that PSA screening will reduce prostate cancer mortality, but it clearly shows an elevated risk of harm.”

“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, says Professor Mark Frydenberg, President-elect of the Urological Society.

“Additionally we would challenge their interpretation of the available evidence.”

“What we need to remember, that while the PSA blood test is 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% and metastases by up to 47%.”

“The interpretation of the data looking at the harms of treatments did not take into account improvements in surgical techniques in recent years that have reduced complication rates. In addition we have evidence if men at age 45 years have a single PSA blood test, that men with the highest 5-10% of PSA levels comprise 50% of the subsequent prostate cancer deaths in the future , hence an ideal population to potentially 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 also not harmed by unnecessary interventions. As always whether to test or not should be dependent on a balanced full discussion of risks and benefits between doctor and patient.

“Today urologists focus on determining which men with abnormal PSA blood tests require a biopsy and then distinguishing between the dangerous and less aggressive tumours and tailoring treatment accordingly to eliminate unnecessary procedures,” Professor Mark Frydenberg said .

Leader of the Genitourinary Oncology Special Advisory Group, Associate Professor, Shomik Sengupta says new diagnostic tools are making accurate diagnosis and treatment plans with the use of multiparametric MRI scanning which can help rule out cancer in men with an elevated PSA, thus potentially eliminating the need for a biopsy.

Biopsies are done via different techniques which can reduce risk of complications such as infection.
“Additionally, if a cancer is found and identified as low risk, these men can be safely monitored with no intervention unless the tumour starts to become aggressive. This is called Active Surveillance and is now accepted as mainstream management of the disease. Australia leads the world in this management practice, with currently around 36% of Australian men with low risk cancer on Active Surveillance – one of the highest rates worldwide – and experiencing little , if any, change to their quality of life,” said Associate Professor Sengupta.

“USANZ 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. The benefits extend beyond reducing death with the potential to reduce distressing symptoms including urinary bleeding, bony pain, kidney failure and spinal cord compression.”

The public consultation for new Australian national draft guidelines on prostate cancer testing are due to be announced on December 4,  by a taskforce headed by the NHMRC that includes representatives from the Urological Society, the College of Pathologists, the College of GPs, Cancer Australia, Colleges of radiation and medical oncology, Evidence based medicine experts and importantly the Prostate Cancer Foundation of Australia who facilitated bringing all these important groups together.

These groups all have crucial roles in managing men with prostate cancer, and will provide evidence and consensus based guidelines to assist Australian men. The Urological Society is proud to be involved in these guidelines and working with our colleagues to provide advice to Australian doctors and men.

Australian guidelines to be announced in December

(Source: USANZ)