Prostate cancer testing is a complex and controversial topic of discussion amongst the community, health professionals, professional societies and policy makers. The debate is due to a current lack of evidence on the effectiveness of PSA (prostate specific antigen) testing as a population-screening method for reducing deaths of men with prostate cancer. Even without a current recommendation for population-wide screening for prostate cancer, PSA testing is widespread in Australia: estimates suggest that more than 50 per cent of Australian men over the age of 50 have had a PSA test 1 . The anticipated and recently released interim results of two large-scale randomised controlled trials in the USA 2 and Europe 3 were hoped to provide more definite answers on the pros and cons of population-screening for prostate cancer. Unfortunately, their results differed and their interpretation was made difficult by the differing study methods. So what do the results mean for men considering having PSA testing and their doctors? In an effort to interpret the results, two commentary papers with an Australian perspective have been released 4 5 . Due to the uncertainty of the results, neither paper recommends population-screening. Instead, men should be informed on the current evidence-base regarding PSA testing, including the benefits and limitations of testing, and the common and significant risks of detection and treatment (such as erectile dysfunction and urinary problems). If the well-informed man chooses to have a PSA test, he should be given one. To ensure that men are well informed, both papers call for more evidence and point to the need for more understanding of the benefits (in essence, the extent to which deaths can be prevented) versus harms (in essence, the burdens of invasive testing and treatment side-effects) that flow from routine PSA testing. Both papers conclude that the current data suggests that a population-screening program using PSA testing would result in over-diagnosis of low grade tumours with over-treatment resulting in significant and unwarranted side-effects. Furthermore it is suggested that testing should only be applied to men with an anticipated life-expectancy of more than seven years making population- screening inappropriate for many elderly men. Population-screening for Prostate Cancer using the PSA Test Issue 32 – Spring 2009 Andrology Australia is supported by a grant from The Australian Government Department of Health and Ageing. Contents 2 Community education Supporting the Lions Australian Prostate Cancer Website 2 Upcoming events Merv’s Have a Crack Day 3 Focus on PSA testing: What everyman (and health professional) needs to know 5 Professional education Practice Nurse Men’s Health Education 5 Research round-up Public Knowledge of Benefits of Prostate Cancer Screening in Europe 6 In brief 6 Latest news The Healthy Male Newsletter of Andrology Australia – Australian Centre of Excellence in Male Reproductive Health In response to the results of the overseas trials, Andrology Australia provided its position on the debate about PSA testing for prostate cancer in the last newsletter; with an ‘Andrology Australia Statement on PSA Testing for Prostate Cancer’. Since then, Andrology Australia has received much feedback from men asking “What do the findings mean for me?” With a lack of conclusive evidence about population-screening, and the recommendation for men to make informed decisions on whether to have a PSA test/DRE (Digital Rectal Examination), it is important that professional societies and health professionals provide a consistent and coherent message on PSA testing to avoid confusion in men considering being tested for prostate cancer. The 'Focus On' for this edition of The Healthy Male is PSA testing from the viewpoint of an individual man considering testing, and aims to communicate the current evidence-base to men, the community and health professionals. It translates the evidence-base into information relevant for discussion between a man and his doctor when considering whether to have a PSA test, and lists additional resources that can help to guide the discussion. We hope this edition of our newsletter helps clarify and guide discussions between men and their doctor in regard to this important health issue. Professor Rob McLachlan From the Director 1 Holden CA et al. Men in Australia Telephone Survey (MATeS): a national survey of the reproductive health and concerns of middle-aged and older Australian men. Lancet 2005; 366: 218-224. 2 Andriole GL et al (2009). Mortality Results from a Randomized Prostate-Cancer Screening Trial. N Engl J Med. 360: 1310-1319 3 Schroder FH et al. Screening and Prostate-Cancer Mortality in a Randomized European Study (2009). N Engl J Med. 360 1320-1328 Andriole GL et al (2009). Mortality Results from a Randomized Prostate-Cancer Screening Trial. N Engl J Med. 360: 1310-1319 4 Barratt A et al. Screening for prostate cancer: explaining new trial results and their implications to patients. MJA 2009; 191: 226-229 5 Smith et al. Evidence-based uncertainty: recent trial results on prostate-specific antigen testing and prostate cancer mortality. MJA 2009; 191: 199-200
Transcript
Prostate cancer testing is a complex and controversial topic of discussion amongst the community, health professionals, professional societies and policy makers. The debate is due to a current lack of evidence on the effectiveness of PSA (prostate specifi c antigen) testing as a population-screening method for reducing deaths of men with prostate cancer.
Even without a current recommendation for population-wide screening for prostate cancer, PSA testing is widespread in Australia: estimates suggest that more than 50 per cent of Australian men over the age of 50 have had a PSA test1.
The anticipated and recently released interim results of two large-scale randomised controlled trials in the USA2 and Europe3 were hoped to provide more defi nite answers on the pros and cons of population-screening for prostate cancer. Unfortunately, their results differed and their interpretation was made diffi cult by the differing study methods. So what do the results mean for men considering having PSA testing and their doctors?
In an effort to interpret the results, two commentary papers with an Australian perspective have been released4 5.
Due to the uncertainty of the results, neither paper recommends population-screening. Instead, men should be informed on the current evidence-base regarding PSA testing, including the benefi ts and limitations of testing, and the common and signifi cant risks of detection and treatment (such as erectile dysfunction and urinary problems). If the well-informed man chooses to have a PSA test, he should be given one. To ensure that men are well informed, both papers call for more evidence and point to the need for more understanding of the benefi ts (in essence, the extent to which deaths can be prevented) versus harms (in essence, the burdens of invasive testing and treatment side-effects) that fl ow from routine PSA testing.
Both papers conclude that the current data suggests that a population-screening program using PSA testing would result in over-diagnosis of low grade tumours with over-treatment resulting in signifi cant and unwarranted side-effects. Furthermore it is suggested that testing should only be applied to men with an anticipated life-expectancy of more than seven years making population-screening inappropriate for many elderly men.
Population-screening for Prostate Cancer using the PSA Test
DISCLAIMER
This newsletter is provided as
an information service.
Information contained in this newsletter is
based on current medical evidence but should
not take the place of proper medical advice
from a qualifi ed health professional. The
services of a qualifi ed medical practitioner
should be sought before applying the
information to particular circumstances.
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In brief
New resources on the Andrology Australia website:
Andrology Australia is pleased to be able to include two new booklets on the website www.andrologyaustralia.org for download.The fi rst booklet, ‘Maintaining your well-being: Information on depression and anxiety for men with prostate cancer and their partners’ was developed by beyondblue: the national depression initiative in partnership with the PCFA. The booklet provides information on common reactions to a diagnosis of prostate cancer, the cancer journey, helpful strategies to deal with prostate cancer, signs of distress, including depression and anxiety, and how to seek help for depression and anxiety. Hard copies are also available from the beyondblue website (www.beyondblue.org.au) or the beyondblue info line (1300 22 46 36).
The second booklet now available to download is the ‘Boys and Puberty: almost everything boys will ever need to know about body changes and other stuff!’. Produced by the Government of Western Australia, Department of Health.
Farewell to Board Member, Professor Doreen Rosenthal AO
Andrology Australia bids a sad farewell to Professor Doreen Rosenthal AO from the Advisory Board. We thank Doreen for her invaluable contribution to the ongoing success of the Andrology Australia program and wish her all the best in her future endeavours.
Professor Doreen Rosenthal AO and
Andrology Australia CEO, Dr Carol Holden
Latest news
PCA3 testing for prostate cancer
A recent study examined whether the level of prostate cancer antigen 3 (PCA3) in the urine following a DRE (Digital Rectal Examination) can be used to help guide the decision to perform a repeat biopsy to confi rm prostate cancer after a raised PSA.
The study suggested possible benefi t of using this urine test in addition to the current PSA test and DRE. The study also explored whether PCA3 could act as an indicator of the clinical stage and aggressiveness of prostate cancer.
Many researchers are looking for new markers of prostate cancer. At this stage, PCA3 is still an experimental test and does not have a place in the routine assessment of prostate disease. There are only a few published studies on PCA3 and diagnostic, cutoff values are not clear and have limited reproducibility. There is no evidence to suggest that the PCA3 test is better than the current testing of PSA and/or DRE in the detection or exclusion of prostate cancer.
While the Internet provides men with access to information about new prostate markers for prostate cancer, PCA3 is not currently approved for use in Australia by the TGA (Therapeutic Goods Administration). While some doctors may offer the technology, as it is not covered by the Medicare Benefi ts Schedule, there may be signifi cant costs to a patient without any rebates being available.
Given the lack of robust evidence, the PCA3 test would potentially raise more doubts than current PSA testing methods and subsequently may increase the rate of biopsies, rather than decrease it.
If you are concerned about prostate cancer, talk to your doctor about the pros and cons of testing using currently available and well-validated methods.
Change of Address
For any future correspondence, please note that our address has changed to:
Andrology AustraliaMonash Institute of Medical ResearchPO Box 5418, Clayton, Victoria, Australia 3168
Issue 32 – Spring 2009
Andrology Australia is supported by a grant from The Australian Government Department of Health and Ageing.
Contents
2 Community education
Supporting the Lions
Australian Prostate Cancer
Website
2 Upcoming events
Merv’s Have a Crack Day
3 Focus on
PSA testing: What everyman
(and health professional)
needs to know
5 Professional education
Practice Nurse Men’s Health
Education
5 Research round-up
Public Knowledge of
Benefi ts of Prostate Cancer
Screening in Europe
6 In brief
6 Latest news
Public Knowledge of Benefi ts of Prostate Cancer Screening in Europe
A recent study1 surveyed 10,228 people across nine European countries to establish the extent of the public’s knowledge of the benefi ts of screening for breast and prostate cancer, to fi nd out whether decisions about testing are likely to be informed. With respect to prostate cancer screening, the study explored whether the public’s knowledge of the benefi ts is realistic, which sources are used for health information, and if the number of times men used the information sources impacts their level of understanding.
The male participants were given a multiple choice question to estimate the number of lives saved by screening after ten years, if 1000 men aged 50 and older had PSA testing every two years. Only 11 per cent of the men surveyed made reasonable estimates (that the number
of prostate cancer deaths prevented for every 1000 men screened was less than or equal to one). The remaining 89 per cent either over-estimated the benefi t or didn’t know. The estimates made by men aged between 50 and 69 were no more correct than those made by men in young age groups.
Family or friends were the most used source of health information, followed by experts (doctors and pharmacists), general media, and lastly health-specifi c resources (including health organisation pamphlets, reference books, health insurance, Internet).
The number of times a man used the sources of information didn’t increase his understanding of the real benefi ts of screening, but was often related to an overestimation of the benefi t.
To ensure men can make informed and rational decisions about whether to have PSA testing, they must be aware of the benefi ts of population-screening (or lack of). An Australian study2 has shown that resources that help patient decision-making used in general practice can increase the doctor’s knowledge and confi dence in discussing testing with men; such as the PSA Decision Card: ‘The Early Detection of Prostate Cancer in General Practice: Supporting Patient Choice’. Available from: www.andrologyaustralia.org/docs/PSAdecisioncard20041007.pdf)
1 Gigerenzer G et al. Public Knowledge of Benefi ts
of Breast and Prostate Cancer Screening in Europe.
JNCI 2009; 101: 1216-1220
2 Steginga S et al. Shared decision-making and
informed choice for the early detection of prostate
cancer in primary care. BJU 2005; 96: 1209-1210
Newsletter of Andrology Australia Australian Centre of Excellence in
Male Reproductive Health
Editor: Sarah Camille
Postal Address:
Andrology Australia Monash Institute of Medical ResearchPO Box 5418, Clayton,Victoria, Australia, 3168
Practice nurses are becoming more widely recognised as an integral part of delivering health information within general practice. Andrology Australia has been working with the Australian Practice Nurses Association (APNA) to identify if a need exists for the development of a men’s health education program developed specifi cally for practice nurses.
A Men’s Health Education Survey was distributed to members of the APNA to determine the information and education needs of practice nurses when engaging men in general practice.
Feedback from the survey showed that the majority of practice nurses had never
undertaken professional education on male reproductive health topics such as erectile dysfunction and prostate disease.
The survey results established a need for the development of a men’s health education program specifi cally targeted toward practice nurses, with 78 per cent of the respondents indicating that they would like further education on men’s health issues within general practice.
To address the need for Practice Nurse Education on men’s health issues, an Andrology Australia Practice Nurse Education Reference Group has been established. The reference group includes practice nurses from across Australia
who have an interest in men’s health, are members of the APNA and have links with their local Division of General Practice.
The reference group will guide and develop a practical education program for practice nurses to deliver current evidence-based men’s health education specifi c to practice nurses across Australia, including rural areas. The initial aim of the reference group is to develop a pilot education program in a format suitable to practice nurse needs and preferred methods of education.
Evaluation of the pilot will help determine areas of improvement for a broader roll-out nation-wide.
The Healthy MaleNewsletter of Andrology Australia – Australian Centre of Excellence in Male Reproductive Health
Public Consultation on draft Clinical Practice Guidelines for the
management of Locally Advanced and Metastatic Prostate CancerThe Australian Cancer Network is inviting public submissions on its draft Clinical Practice Guidelines for the Management of Locally Advanced and Metastatic Prostate Cancer. The guidelines address the management of locally advanced and metastatic prostate cancer including clinical, psychosocial and palliative aspects of the disease.The draft document and directions on how to make a submission can be viewed and downloaded from the ACN website at www.cancer.org.au/clinical_guidelines. Submissions close 5 October 2009.
In response to the results of the overseas trials, Andrology Australia provided its position on the debate about PSA testing for prostate cancer in the last newsletter; with an ‘Andrology Australia Statement on PSA Testing for Prostate Cancer’. Since then, Andrology Australia has received much feedback from men asking “What do the fi ndings mean for me?”
With a lack of conclusive evidence about population-screening, and the recommendation for men to make informed decisions on whether to have a PSA test/DRE (Digital Rectal Examination), it is important that professional societies and health professionals provide a consistent and coherent message on PSA testing to avoid confusion in men considering being tested for prostate cancer.
The 'Focus On' for this edition of The Healthy
Male is PSA testing from the viewpoint of an individual man considering testing, and aims to communicate the current evidence-base to men, the community and health professionals. It translates the evidence-base into information relevant for discussion between a man and his doctor when considering whether to have a PSA test, and lists additional resources that can help to guide the discussion.
We hope this edition of our newsletter helps clarify and guide discussions between men and their doctor in regard to this important health issue.
Professor Rob McLachlan
From
the
Dir
ecto
r
1 Holden CA et al. Men in Australia Telephone Survey (MATeS): a national survey of the reproductive health and concerns of middle-aged and older Australian men. Lancet 2005; 366: 218-224.
2 Andriole GL et al (2009). Mortality Results from a Randomized Prostate-Cancer Screening Trial. N Engl J Med. 360: 1310-1319
3 Schroder FH et al. Screening and Prostate-Cancer Mortality in a Randomized European Study (2009). N Engl J Med. 360 1320-1328 Andriole GL et al (2009). Mortality Results from a
Randomized Prostate-Cancer Screening Trial. N Engl J Med. 360: 1310-1319
4 Barratt A et al. Screening for prostate cancer: explaining new trial results and their implications to patients. MJA 2009; 191: 226-229
5 Smith et al. Evidence-based uncertainty: recent trial results on prostate-specifi c antigen testing and prostate cancer mortality. MJA 2009; 191: 199-200
Time is passing quickly and momentum is gathering for the fi rst Andrology Australia Merv’s Have a Crack Day event on December 11,
2009. There has been a tremendous amount of interest in teams registering and companies securing their place in sponsoring the event, which will become an annual and coveted fi xture on Melbourne’s sporting calendar. More sponsorship opportunities and teams are available, but are fi lling up fast, so register your interest today at www.mervshaveacrackday.com.au.
The fi rst group of cricketing legends have been confi rmed. Merv's great mates and fellow Aussie legends Ian Healy, David Boon, Damien Fleming and
Rodney Hogg are all starters, and will be joined by an eclectic mix of Australia’s other sporting code and entertainment celebrities yet to be announced.
The latest celebrity cricketer to be announced boasts one of the longest bowling run ups in the history of cricket at 42km. Australian Olympic Champion Steve Monaghetti has confi rmed his attendance on the day and support of the importance of raising awareness of men’s health. The event will be offi cially opened by and participated in by cricket lover and men’s health advocate, the Governor of Victoria, Professor David de Kretser AC who is also Patron of Andrology Australia.
Andrology Australia also welcomes and is proud to announce ‘Diadora’ as the offi cial merchandise and apparel event sponsor. Diadora is a leading Italian sports brand and it’s licence in Australia is owned by Overland Group (Australasia) Pty Ltd.
The unique opportunity to register a team for the event or secure the limited categories of event sponsorship available will soon close. Register your interest today on the Merv’s Have a Crack website atwww.mervshaveacrackday.com.au
Community education
The Lions Australian Prostate Cancer website was established in 2000 by the education committee of the Australian Prostate Cancer Collaboration (APCC). The website was developed in response to a needs assessment survey of men with prostate cancer, which was done with the help of the Association of Prostate Cancer Support Groups (now the Support and Advocacy Committee of the Prostate Cancer Foundation of Australia).
Development funding was kindly provided by Lions Australia, and the website was supported in kind by the Repatriation General Hospital as the developer of much of the original content. The site received a Public Health Association of Australasia Award in 2001.
The site assists men affected by prostate cancer and their families by providing information on prostate cancer and treatment options, educational resources and stories and experiences.
It also has an online helpline. The site attracts 400,000 hits and 45,000 visitor sessions per month. Since its development, the content of the site has been contributed to and updated by the education committee of the APCC, which includes representatives of the Cancer Councils across Australia.
In continuing to support the quality and evidence-based prostate cancer education activities and information developed by the Australian Prostate Cancer Collaboration, which will cease operations in 2009, Andrology Australia is pleased to take on the management of the Lions Australian Prostate Cancer website (www.prostatehealth.org.au).
Andrology Australia will continue to work with the education committee of the Australian Prostate Cancer Collaboration and Lions Australia to ensure that the content of the site is kept up to date and
provides men and their families with accurate and evidence-based information on prostate cancer.
We look forward to an ongoing collaboration with Lions Australia and continuing to provide accessible sources of information on prostate cancer.
Supporting the Lions Australian Prostate Cancer Website
Merv’s Have a Crack Day Update
Upcoming events
Focus on: PSA testing: What everyman (and health professional) needs to knowAuthor: Professor RA 'Frank' Gardiner
Although there is limited evidence that PSA testing reduces the risk of death from prostate cancer, there has been a noticeable change recently with more men now asking for information about being tested.
To ensure men are able to make informed decisions about whether to be tested for prostate cancer, it is important that evidence-based information about the current state of knowledge about PSA testing is provided to men, the community and health professionals in a form that they can easily understand; including the physical and psychological impact the decision and diagnosis may have.
What is a PSA test and when is it used?
Prostate Specifi c Antigen (PSA) is a protein made mainly in the prostate and is normally found in low levels in a man’s blood stream. A PSA test measures the level of PSA in the blood and may help to diagnose prostate disease. A high PSA in the blood almost always means that something is wrong with the prostate, but not necessarily prostate cancer.
A high PSA may be found in men who have prostatitis (infection or infl ammation of the prostate), benign prostatic hyperplasia (BPH known as prostate enlargement), or least commonly, prostate cancer.
Why is the decision to have a PSA test a complex one?
A single PSA test is not a reliable sign of prostate cancer on its own. Once a decision is made to be tested for prostate cancer, a man starts on a ‘testing journey’ made up of three stages that can continue for the rest of his life. If the additional stages are not discussed with a man prior to his decision to have the fi rst PSA test and he receives an abnormal PSA result, the additional stages can be highly unexpected and may cause psychological distress.
The decision to have a PSA test should be made with the understanding of all possible outcomes; including the physical and psychological side-effects that can come with further testing, prostate cancer diagnosis and its various treatment options, which may include erectile dysfunction and continence problems.
For men diagnosed with prostate cancer, there are three treatment possibilities: i) curative intent (radical prostatectomy or radiation therapy); ii) commencement of androgen deprivation therapy (ADT) following monitoring (watchful waiting) and iii) active surveillance (which includes further biopsies). Monitoring may be measuring PSA (+/- DRE) with a view to commencing ADT at some later date or by active surveillance (involving PSA, DRE and further biopsies). An increasing number of men diagnosed with prostate cancer are proceeding to active surveillance for what is considered to be cancer with a low-risk of progression; with the option of radical prostatectomy or radiation therapy reserved for those men whose cancers subsequently show evidence of progressing as revealed by intense monitoring.
A cancer diagnosis is complicated by the fact that in about 1 in 4 men prostate cancer may act in an aggressive fashion (e.g. spread to lymph nodes and to bone which may have already occurred at
presentation but may not be demonstrable with imaging tests), while in another 1 in 4 men the cancer remains indolent (e.g. remaining localised to the prostate). At this stage there is no useful marker to identify which cancers will behave in an indolent or an aggressive fashion.
One in eight men diagnosed with prostate cancer will die of the disease with this number varying depending on age and Gleason score of disease at diagnosis, with younger men diagnosed with more advanced cancer more likely to die from the disease (as there are fewer competing causes of death or co-morbidities, such as cardiovascular disease which is increasingly common as men become older.)
What if I’m a man thinking about prostate cancer testing?
Men should be aware that there is debate about the potential gains and risks from PSA testing and prostate cancer treatment options. If you are considering having your fi rst PSA test/DRE, you should discuss the following with your doctor and use the resources listed to help guide the discussion:
PSA levels rise as a normal part of ageing as the prostate tends >to grow larger so the ‘normal’ levels (or reference range) of PSA must be adjusted for a man’s age. Even when the PSA level is within the normal range for that age group, a PSA velocity (the time it takes for PSA levels to increase, such as a doubling over 12 months) trigger further investigation by your doctor
Increases in single PSA levels taken at age 40 years (cut-off >0.6 ng/ml) and 50 years (cut-off 1.5 ng/ml) may suggest an increased risk of prostate cancer over the next 10-20 years
The combination of a DRE with a PSA improves detection rates. >However a DRE only allows a doctor to feel that part of the prostate immediately in front of the rectum (back passage) but not the other areas of the prostate that could also be affected by cancer
An abnormal PSA/DRE needs further assessment by a urologist >(specialist) to confi rm if this is due to a growing cancer or a non-cancerous problem such as prostatitis (infl ammation due to infection) or benign prostatic hyperplasia (BPH)
The limitations of PSA testing should be discussed with your >doctor; including the inability of the PSA test to confi rm prostate cancer or to detect how advanced the cancer is and how quickly it is progressing
A normal PSA test (combined with a negative DRE) reduces the >chance that prostate cancer is present but does not exclude it completely
There is no level of PSA that identifi es whether a man does or >does not have prostate cancer
What if I have a family history of prostate cancer?
Men with a strong family history of prostate cancer (whether a grandfather, father, brother, uncle or cousin with the disease) are at a greater risk of cancer and should think about being tested from 40 years of age. On average, hereditary prostate cancer may develop six years earlier than non-hereditary prostate cancer.
A history of breast cancer in female family members can also be linked with a higher risk of prostate cancer in men. It is important to discuss any family history of disease with your doctor.
What if I’m a health professional talking to my
patients about prostate cancer testing?
Being tested for prostate cancer should be a shared decision-making discussion between a man and his doctor, and should only happen if a man is properly informed of the potential gains and risks of testing and then agrees to proceed with testing. It is not appropriate to order a PSA test without a patient’s knowledge or as part of a suite of blood tests unless the patient has been adequately informed.
It is essential that any health professional ordering and discussing PSA testing is up-to-date with the scientifi c evidence and ensures that balanced evidence-based information and resources are provided to the patient before a decision is made.
A man seeking PSA testing should be given access to written or web-based, relevant material which is evidence-based (when this is available), is easy to read and understand, and is endorsed by reputable professional bodies. Any information provided should be
given in a way that respects the man’s education level, personal circumstances, language skills and culture, and is sensitive to the man’s values and personal preferences. It should not be assumed that patients requesting PSA testing are adequately informed.
Health practitioners should recognise that an abnormal PSA test followed by a biopsy, that shows even low-risk cancer, may have the potential to cause anxiety and distress for some men. However, providing information and support is likely to help men to maintain a good quality of life without psychosocial stress, even if there is a cancer diagnosis. Such support is particularly important through all stages of testing and treatment.
Referral to a urologist is essential for assessment of an abnormal PSA result including a low free/total PSA ratio, or a rapidly rising PSA. Early referral to a urologist is recommended for consideration of transrectal ultrasound (TRUS)-guided biopsy. The urologist must provide full information about the possible TRUS fi ndings, risks and subsequent management options to the man and his doctor.
What health information and resources are available
on PSA testing?
Current resources which provide information based on the current evidence available include:
Andrology Australia website (www.andrologyaustralia.org) >
Topic: ‘Whether to test for Prostate Cancer’ (including PSA Decision Card)
Topic ‘Pertinent Points in Prostate Cancer’ Appendix 2: Age-related ranges for Caucasian and Asian men
Lions Australian Prostate Cancer website >(www.prostatehealth.org.au)
PSA Decision Card: ‘The Early Detection of Prostate Cancer in >General Practice: Supporting Patient Choice’. Available from: www.andrologyaustralia.org/docs/PSAdecisioncard20041007.pdf
Where do we go from here?
Newer and more specifi c prostate cancer markers are needed before an effective population-wide prostate cancer screening program can be trialled, recommended or implemented. The key challenge for any prostate cancer population-screening program is to identify men with aggressive cancer, and to intervene early and effectively.
There is no current recommendation for population-wide screening for prostate cancer in Australia by government or professional societies, including the Urological Society of Australia and New Zealand and the Cancer Councils of Australia. This lack of recommendation is due to the lack of evidence.
Until such evidence is available, targeted testing of informed individuals is considered appropriate practice. PSA testing combined with DRE is currently considered to be the most suitable method of identifying men at risk of having prostate cancer.
A full list of references for this article is available by emailing [email protected].
STAGE ONE:
STAGE TWO:
STAGE THREE:
TREATMENT WITH CURATIVE
INTENT & MONITORING
Or
WATCHFUL WAITING
PSA LEVEL
FURTHER TESTING
MANAGEMENT
ACTIVE
SURVEILLANCE
Prostate cancer ‘Testing Journey’
Time is passing quickly and momentum is gathering for the fi rst Andrology Australia Merv’s Have a Crack Day event on December 11,
2009. There has been a tremendous amount of interest in teams registering and companies securing their place in sponsoring the event, which will become an annual and coveted fi xture on Melbourne’s sporting calendar. More sponsorship opportunities and teams are available, but are fi lling up fast, so register your interest today at www.mervshaveacrackday.com.au.
The fi rst group of cricketing legends have been confi rmed. Merv's great mates and fellow Aussie legends Ian Healy, David Boon, Damien Fleming and
Rodney Hogg are all starters, and will be joined by an eclectic mix of Australia’s other sporting code and entertainment celebrities yet to be announced.
The latest celebrity cricketer to be announced boasts one of the longest bowling run ups in the history of cricket at 42km. Australian Olympic Champion Steve Monaghetti has confi rmed his attendance on the day and support of the importance of raising awareness of men’s health. The event will be offi cially opened by and participated in by cricket lover and men’s health advocate, the Governor of Victoria, Professor David de Kretser AC who is also Patron of Andrology Australia.
Andrology Australia also welcomes and is proud to announce ‘Diadora’ as the offi cial merchandise and apparel event sponsor. Diadora is a leading Italian sports brand and it’s licence in Australia is owned by Overland Group (Australasia) Pty Ltd.
The unique opportunity to register a team for the event or secure the limited categories of event sponsorship available will soon close. Register your interest today on the Merv’s Have a Crack website atwww.mervshaveacrackday.com.au
Community education
The Lions Australian Prostate Cancer website was established in 2000 by the education committee of the Australian Prostate Cancer Collaboration (APCC). The website was developed in response to a needs assessment survey of men with prostate cancer, which was done with the help of the Association of Prostate Cancer Support Groups (now the Support and Advocacy Committee of the Prostate Cancer Foundation of Australia).
Development funding was kindly provided by Lions Australia, and the website was supported in kind by the Repatriation General Hospital as the developer of much of the original content. The site received a Public Health Association of Australasia Award in 2001.
The site assists men affected by prostate cancer and their families by providing information on prostate cancer and treatment options, educational resources and stories and experiences.
It also has an online helpline. The site attracts 400,000 hits and 45,000 visitor sessions per month. Since its development, the content of the site has been contributed to and updated by the education committee of the APCC, which includes representatives of the Cancer Councils across Australia.
In continuing to support the quality and evidence-based prostate cancer education activities and information developed by the Australian Prostate Cancer Collaboration, which will cease operations in 2009, Andrology Australia is pleased to take on the management of the Lions Australian Prostate Cancer website (www.prostatehealth.org.au).
Andrology Australia will continue to work with the education committee of the Australian Prostate Cancer Collaboration and Lions Australia to ensure that the content of the site is kept up to date and
provides men and their families with accurate and evidence-based information on prostate cancer.
We look forward to an ongoing collaboration with Lions Australia and continuing to provide accessible sources of information on prostate cancer.
Supporting the Lions Australian Prostate Cancer Website
Merv’s Have a Crack Day Update
Upcoming events
Focus on: PSA testing: What everyman (and health professional) needs to knowAuthor: Professor RA 'Frank' Gardiner
Although there is limited evidence that PSA testing reduces the risk of death from prostate cancer, there has been a noticeable change recently with more men now asking for information about being tested.
To ensure men are able to make informed decisions about whether to be tested for prostate cancer, it is important that evidence-based information about the current state of knowledge about PSA testing is provided to men, the community and health professionals in a form that they can easily understand; including the physical and psychological impact the decision and diagnosis may have.
What is a PSA test and when is it used?
Prostate Specifi c Antigen (PSA) is a protein made mainly in the prostate and is normally found in low levels in a man’s blood stream. A PSA test measures the level of PSA in the blood and may help to diagnose prostate disease. A high PSA in the blood almost always means that something is wrong with the prostate, but not necessarily prostate cancer.
A high PSA may be found in men who have prostatitis (infection or infl ammation of the prostate), benign prostatic hyperplasia (BPH known as prostate enlargement), or least commonly, prostate cancer.
Why is the decision to have a PSA test a complex one?
A single PSA test is not a reliable sign of prostate cancer on its own. Once a decision is made to be tested for prostate cancer, a man starts on a ‘testing journey’ made up of three stages that can continue for the rest of his life. If the additional stages are not discussed with a man prior to his decision to have the fi rst PSA test and he receives an abnormal PSA result, the additional stages can be highly unexpected and may cause psychological distress.
The decision to have a PSA test should be made with the understanding of all possible outcomes; including the physical and psychological side-effects that can come with further testing, prostate cancer diagnosis and its various treatment options, which may include erectile dysfunction and continence problems.
For men diagnosed with prostate cancer, there are three treatment possibilities: i) curative intent (radical prostatectomy or radiation therapy); ii) commencement of androgen deprivation therapy (ADT) following monitoring (watchful waiting) and iii) active surveillance (which includes further biopsies). Monitoring may be measuring PSA (+/- DRE) with a view to commencing ADT at some later date or by active surveillance (involving PSA, DRE and further biopsies). An increasing number of men diagnosed with prostate cancer are proceeding to active surveillance for what is considered to be cancer with a low-risk of progression; with the option of radical prostatectomy or radiation therapy reserved for those men whose cancers subsequently show evidence of progressing as revealed by intense monitoring.
A cancer diagnosis is complicated by the fact that in about 1 in 4 men prostate cancer may act in an aggressive fashion (e.g. spread to lymph nodes and to bone which may have already occurred at
presentation but may not be demonstrable with imaging tests), while in another 1 in 4 men the cancer remains indolent (e.g. remaining localised to the prostate). At this stage there is no useful marker to identify which cancers will behave in an indolent or an aggressive fashion.
One in eight men diagnosed with prostate cancer will die of the disease with this number varying depending on age and Gleason score of disease at diagnosis, with younger men diagnosed with more advanced cancer more likely to die from the disease (as there are fewer competing causes of death or co-morbidities, such as cardiovascular disease which is increasingly common as men become older.)
What if I’m a man thinking about prostate cancer testing?
Men should be aware that there is debate about the potential gains and risks from PSA testing and prostate cancer treatment options. If you are considering having your fi rst PSA test/DRE, you should discuss the following with your doctor and use the resources listed to help guide the discussion:
PSA levels rise as a normal part of ageing as the prostate tends >to grow larger so the ‘normal’ levels (or reference range) of PSA must be adjusted for a man’s age. Even when the PSA level is within the normal range for that age group, a PSA velocity (the time it takes for PSA levels to increase, such as a doubling over 12 months) trigger further investigation by your doctor
Increases in single PSA levels taken at age 40 years (cut-off >0.6 ng/ml) and 50 years (cut-off 1.5 ng/ml) may suggest an increased risk of prostate cancer over the next 10-20 years
The combination of a DRE with a PSA improves detection rates. >However a DRE only allows a doctor to feel that part of the prostate immediately in front of the rectum (back passage) but not the other areas of the prostate that could also be affected by cancer
An abnormal PSA/DRE needs further assessment by a urologist >(specialist) to confi rm if this is due to a growing cancer or a non-cancerous problem such as prostatitis (infl ammation due to infection) or benign prostatic hyperplasia (BPH)
The limitations of PSA testing should be discussed with your >doctor; including the inability of the PSA test to confi rm prostate cancer or to detect how advanced the cancer is and how quickly it is progressing
A normal PSA test (combined with a negative DRE) reduces the >chance that prostate cancer is present but does not exclude it completely
There is no level of PSA that identifi es whether a man does or >does not have prostate cancer
What if I have a family history of prostate cancer?
Men with a strong family history of prostate cancer (whether a grandfather, father, brother, uncle or cousin with the disease) are at a greater risk of cancer and should think about being tested from 40 years of age. On average, hereditary prostate cancer may develop six years earlier than non-hereditary prostate cancer.
A history of breast cancer in female family members can also be linked with a higher risk of prostate cancer in men. It is important to discuss any family history of disease with your doctor.
What if I’m a health professional talking to my
patients about prostate cancer testing?
Being tested for prostate cancer should be a shared decision-making discussion between a man and his doctor, and should only happen if a man is properly informed of the potential gains and risks of testing and then agrees to proceed with testing. It is not appropriate to order a PSA test without a patient’s knowledge or as part of a suite of blood tests unless the patient has been adequately informed.
It is essential that any health professional ordering and discussing PSA testing is up-to-date with the scientifi c evidence and ensures that balanced evidence-based information and resources are provided to the patient before a decision is made.
A man seeking PSA testing should be given access to written or web-based, relevant material which is evidence-based (when this is available), is easy to read and understand, and is endorsed by reputable professional bodies. Any information provided should be
given in a way that respects the man’s education level, personal circumstances, language skills and culture, and is sensitive to the man’s values and personal preferences. It should not be assumed that patients requesting PSA testing are adequately informed.
Health practitioners should recognise that an abnormal PSA test followed by a biopsy, that shows even low-risk cancer, may have the potential to cause anxiety and distress for some men. However, providing information and support is likely to help men to maintain a good quality of life without psychosocial stress, even if there is a cancer diagnosis. Such support is particularly important through all stages of testing and treatment.
Referral to a urologist is essential for assessment of an abnormal PSA result including a low free/total PSA ratio, or a rapidly rising PSA. Early referral to a urologist is recommended for consideration of transrectal ultrasound (TRUS)-guided biopsy. The urologist must provide full information about the possible TRUS fi ndings, risks and subsequent management options to the man and his doctor.
What health information and resources are available
on PSA testing?
Current resources which provide information based on the current evidence available include:
Andrology Australia website (www.andrologyaustralia.org) >
Topic: ‘Whether to test for Prostate Cancer’ (including PSA Decision Card)
Topic ‘Pertinent Points in Prostate Cancer’ Appendix 2: Age-related ranges for Caucasian and Asian men
Lions Australian Prostate Cancer website >(www.prostatehealth.org.au)
PSA Decision Card: ‘The Early Detection of Prostate Cancer in >General Practice: Supporting Patient Choice’. Available from: www.andrologyaustralia.org/docs/PSAdecisioncard20041007.pdf
Where do we go from here?
Newer and more specifi c prostate cancer markers are needed before an effective population-wide prostate cancer screening program can be trialled, recommended or implemented. The key challenge for any prostate cancer population-screening program is to identify men with aggressive cancer, and to intervene early and effectively.
There is no current recommendation for population-wide screening for prostate cancer in Australia by government or professional societies, including the Urological Society of Australia and New Zealand and the Cancer Councils of Australia. This lack of recommendation is due to the lack of evidence.
Until such evidence is available, targeted testing of informed individuals is considered appropriate practice. PSA testing combined with DRE is currently considered to be the most suitable method of identifying men at risk of having prostate cancer.
A full list of references for this article is available by emailing [email protected].
STAGE ONE:
STAGE TWO:
STAGE THREE:
TREATMENT WITH CURATIVE
INTENT & MONITORING
Or
WATCHFUL WAITING
PSA LEVEL
FURTHER TESTING
MANAGEMENT
ACTIVE
SURVEILLANCE
Prostate cancer ‘Testing Journey’
Time is passing quickly and momentum is gathering for the fi rst Andrology Australia Merv’s Have a Crack Day event on December 11,
2009. There has been a tremendous amount of interest in teams registering and companies securing their place in sponsoring the event, which will become an annual and coveted fi xture on Melbourne’s sporting calendar. More sponsorship opportunities and teams are available, but are fi lling up fast, so register your interest today at www.mervshaveacrackday.com.au.
The fi rst group of cricketing legends have been confi rmed. Merv's great mates and fellow Aussie legends Ian Healy, David Boon, Damien Fleming and
Rodney Hogg are all starters, and will be joined by an eclectic mix of Australia’s other sporting code and entertainment celebrities yet to be announced.
The latest celebrity cricketer to be announced boasts one of the longest bowling run ups in the history of cricket at 42km. Australian Olympic Champion Steve Monaghetti has confi rmed his attendance on the day and support of the importance of raising awareness of men’s health. The event will be offi cially opened by and participated in by cricket lover and men’s health advocate, the Governor of Victoria, Professor David de Kretser AC who is also Patron of Andrology Australia.
Andrology Australia also welcomes and is proud to announce ‘Diadora’ as the offi cial merchandise and apparel event sponsor. Diadora is a leading Italian sports brand and it’s licence in Australia is owned by Overland Group (Australasia) Pty Ltd.
The unique opportunity to register a team for the event or secure the limited categories of event sponsorship available will soon close. Register your interest today on the Merv’s Have a Crack website atwww.mervshaveacrackday.com.au
Community education
The Lions Australian Prostate Cancer website was established in 2000 by the education committee of the Australian Prostate Cancer Collaboration (APCC). The website was developed in response to a needs assessment survey of men with prostate cancer, which was done with the help of the Association of Prostate Cancer Support Groups (now the Support and Advocacy Committee of the Prostate Cancer Foundation of Australia).
Development funding was kindly provided by Lions Australia, and the website was supported in kind by the Repatriation General Hospital as the developer of much of the original content. The site received a Public Health Association of Australasia Award in 2001.
The site assists men affected by prostate cancer and their families by providing information on prostate cancer and treatment options, educational resources and stories and experiences.
It also has an online helpline. The site attracts 400,000 hits and 45,000 visitor sessions per month. Since its development, the content of the site has been contributed to and updated by the education committee of the APCC, which includes representatives of the Cancer Councils across Australia.
In continuing to support the quality and evidence-based prostate cancer education activities and information developed by the Australian Prostate Cancer Collaboration, which will cease operations in 2009, Andrology Australia is pleased to take on the management of the Lions Australian Prostate Cancer website (www.prostatehealth.org.au).
Andrology Australia will continue to work with the education committee of the Australian Prostate Cancer Collaboration and Lions Australia to ensure that the content of the site is kept up to date and
provides men and their families with accurate and evidence-based information on prostate cancer.
We look forward to an ongoing collaboration with Lions Australia and continuing to provide accessible sources of information on prostate cancer.
Supporting the Lions Australian Prostate Cancer Website
Merv’s Have a Crack Day Update
Upcoming events
Focus on: PSA testing: What everyman (and health professional) needs to knowAuthor: Professor RA 'Frank' Gardiner
Although there is limited evidence that PSA testing reduces the risk of death from prostate cancer, there has been a noticeable change recently with more men now asking for information about being tested.
To ensure men are able to make informed decisions about whether to be tested for prostate cancer, it is important that evidence-based information about the current state of knowledge about PSA testing is provided to men, the community and health professionals in a form that they can easily understand; including the physical and psychological impact the decision and diagnosis may have.
What is a PSA test and when is it used?
Prostate Specifi c Antigen (PSA) is a protein made mainly in the prostate and is normally found in low levels in a man’s blood stream. A PSA test measures the level of PSA in the blood and may help to diagnose prostate disease. A high PSA in the blood almost always means that something is wrong with the prostate, but not necessarily prostate cancer.
A high PSA may be found in men who have prostatitis (infection or infl ammation of the prostate), benign prostatic hyperplasia (BPH known as prostate enlargement), or least commonly, prostate cancer.
Why is the decision to have a PSA test a complex one?
A single PSA test is not a reliable sign of prostate cancer on its own. Once a decision is made to be tested for prostate cancer, a man starts on a ‘testing journey’ made up of three stages that can continue for the rest of his life. If the additional stages are not discussed with a man prior to his decision to have the fi rst PSA test and he receives an abnormal PSA result, the additional stages can be highly unexpected and may cause psychological distress.
The decision to have a PSA test should be made with the understanding of all possible outcomes; including the physical and psychological side-effects that can come with further testing, prostate cancer diagnosis and its various treatment options, which may include erectile dysfunction and continence problems.
For men diagnosed with prostate cancer, there are three treatment possibilities: i) curative intent (radical prostatectomy or radiation therapy); ii) commencement of androgen deprivation therapy (ADT) following monitoring (watchful waiting) and iii) active surveillance (which includes further biopsies). Monitoring may be measuring PSA (+/- DRE) with a view to commencing ADT at some later date or by active surveillance (involving PSA, DRE and further biopsies). An increasing number of men diagnosed with prostate cancer are proceeding to active surveillance for what is considered to be cancer with a low-risk of progression; with the option of radical prostatectomy or radiation therapy reserved for those men whose cancers subsequently show evidence of progressing as revealed by intense monitoring.
A cancer diagnosis is complicated by the fact that in about 1 in 4 men prostate cancer may act in an aggressive fashion (e.g. spread to lymph nodes and to bone which may have already occurred at
presentation but may not be demonstrable with imaging tests), while in another 1 in 4 men the cancer remains indolent (e.g. remaining localised to the prostate). At this stage there is no useful marker to identify which cancers will behave in an indolent or an aggressive fashion.
One in eight men diagnosed with prostate cancer will die of the disease with this number varying depending on age and Gleason score of disease at diagnosis, with younger men diagnosed with more advanced cancer more likely to die from the disease (as there are fewer competing causes of death or co-morbidities, such as cardiovascular disease which is increasingly common as men become older.)
What if I’m a man thinking about prostate cancer testing?
Men should be aware that there is debate about the potential gains and risks from PSA testing and prostate cancer treatment options. If you are considering having your fi rst PSA test/DRE, you should discuss the following with your doctor and use the resources listed to help guide the discussion:
PSA levels rise as a normal part of ageing as the prostate tends >to grow larger so the ‘normal’ levels (or reference range) of PSA must be adjusted for a man’s age. Even when the PSA level is within the normal range for that age group, a PSA velocity (the time it takes for PSA levels to increase, such as a doubling over 12 months) trigger further investigation by your doctor
Increases in single PSA levels taken at age 40 years (cut-off >0.6 ng/ml) and 50 years (cut-off 1.5 ng/ml) may suggest an increased risk of prostate cancer over the next 10-20 years
The combination of a DRE with a PSA improves detection rates. >However a DRE only allows a doctor to feel that part of the prostate immediately in front of the rectum (back passage) but not the other areas of the prostate that could also be affected by cancer
An abnormal PSA/DRE needs further assessment by a urologist >(specialist) to confi rm if this is due to a growing cancer or a non-cancerous problem such as prostatitis (infl ammation due to infection) or benign prostatic hyperplasia (BPH)
The limitations of PSA testing should be discussed with your >doctor; including the inability of the PSA test to confi rm prostate cancer or to detect how advanced the cancer is and how quickly it is progressing
A normal PSA test (combined with a negative DRE) reduces the >chance that prostate cancer is present but does not exclude it completely
There is no level of PSA that identifi es whether a man does or >does not have prostate cancer
What if I have a family history of prostate cancer?
Men with a strong family history of prostate cancer (whether a grandfather, father, brother, uncle or cousin with the disease) are at a greater risk of cancer and should think about being tested from 40 years of age. On average, hereditary prostate cancer may develop six years earlier than non-hereditary prostate cancer.
A history of breast cancer in female family members can also be linked with a higher risk of prostate cancer in men. It is important to discuss any family history of disease with your doctor.
What if I’m a health professional talking to my
patients about prostate cancer testing?
Being tested for prostate cancer should be a shared decision-making discussion between a man and his doctor, and should only happen if a man is properly informed of the potential gains and risks of testing and then agrees to proceed with testing. It is not appropriate to order a PSA test without a patient’s knowledge or as part of a suite of blood tests unless the patient has been adequately informed.
It is essential that any health professional ordering and discussing PSA testing is up-to-date with the scientifi c evidence and ensures that balanced evidence-based information and resources are provided to the patient before a decision is made.
A man seeking PSA testing should be given access to written or web-based, relevant material which is evidence-based (when this is available), is easy to read and understand, and is endorsed by reputable professional bodies. Any information provided should be
given in a way that respects the man’s education level, personal circumstances, language skills and culture, and is sensitive to the man’s values and personal preferences. It should not be assumed that patients requesting PSA testing are adequately informed.
Health practitioners should recognise that an abnormal PSA test followed by a biopsy, that shows even low-risk cancer, may have the potential to cause anxiety and distress for some men. However, providing information and support is likely to help men to maintain a good quality of life without psychosocial stress, even if there is a cancer diagnosis. Such support is particularly important through all stages of testing and treatment.
Referral to a urologist is essential for assessment of an abnormal PSA result including a low free/total PSA ratio, or a rapidly rising PSA. Early referral to a urologist is recommended for consideration of transrectal ultrasound (TRUS)-guided biopsy. The urologist must provide full information about the possible TRUS fi ndings, risks and subsequent management options to the man and his doctor.
What health information and resources are available
on PSA testing?
Current resources which provide information based on the current evidence available include:
Andrology Australia website (www.andrologyaustralia.org) >
Topic: ‘Whether to test for Prostate Cancer’ (including PSA Decision Card)
Topic ‘Pertinent Points in Prostate Cancer’ Appendix 2: Age-related ranges for Caucasian and Asian men
Lions Australian Prostate Cancer website >(www.prostatehealth.org.au)
PSA Decision Card: ‘The Early Detection of Prostate Cancer in >General Practice: Supporting Patient Choice’. Available from: www.andrologyaustralia.org/docs/PSAdecisioncard20041007.pdf
Where do we go from here?
Newer and more specifi c prostate cancer markers are needed before an effective population-wide prostate cancer screening program can be trialled, recommended or implemented. The key challenge for any prostate cancer population-screening program is to identify men with aggressive cancer, and to intervene early and effectively.
There is no current recommendation for population-wide screening for prostate cancer in Australia by government or professional societies, including the Urological Society of Australia and New Zealand and the Cancer Councils of Australia. This lack of recommendation is due to the lack of evidence.
Until such evidence is available, targeted testing of informed individuals is considered appropriate practice. PSA testing combined with DRE is currently considered to be the most suitable method of identifying men at risk of having prostate cancer.
A full list of references for this article is available by emailing [email protected].
STAGE ONE:
STAGE TWO:
STAGE THREE:
TREATMENT WITH CURATIVE
INTENT & MONITORING
Or
WATCHFUL WAITING
PSA LEVEL
FURTHER TESTING
MANAGEMENT
ACTIVE
SURVEILLANCE
Prostate cancer ‘Testing Journey’
Prostate cancer testing is a complex and controversial topic of discussion amongst the community, health professionals, professional societies and policy makers. The debate is due to a current lack of evidence on the effectiveness of PSA (prostate specifi c antigen) testing as a population-screening method for reducing deaths of men with prostate cancer.
Even without a current recommendation for population-wide screening for prostate cancer, PSA testing is widespread in Australia: estimates suggest that more than 50 per cent of Australian men over the age of 50 have had a PSA test1.
The anticipated and recently released interim results of two large-scale randomised controlled trials in the USA2 and Europe3 were hoped to provide more defi nite answers on the pros and cons of population-screening for prostate cancer. Unfortunately, their results differed and their interpretation was made diffi cult by the differing study methods. So what do the results mean for men considering having PSA testing and their doctors?
In an effort to interpret the results, two commentary papers with an Australian perspective have been released4 5.
Due to the uncertainty of the results, neither paper recommends population-screening. Instead, men should be informed on the current evidence-base regarding PSA testing, including the benefi ts and limitations of testing, and the common and signifi cant risks of detection and treatment (such as erectile dysfunction and urinary problems). If the well-informed man chooses to have a PSA test, he should be given one. To ensure that men are well informed, both papers call for more evidence and point to the need for more understanding of the benefi ts (in essence, the extent to which deaths can be prevented) versus harms (in essence, the burdens of invasive testing and treatment side-effects) that fl ow from routine PSA testing.
Both papers conclude that the current data suggests that a population-screening program using PSA testing would result in over-diagnosis of low grade tumours with over-treatment resulting in signifi cant and unwarranted side-effects. Furthermore it is suggested that testing should only be applied to men with an anticipated life-expectancy of more than seven years making population-screening inappropriate for many elderly men.
Population-screening for Prostate Cancer using the PSA Test
DISCLAIMER
This newsletter is provided as
an information service.
Information contained in this newsletter is
based on current medical evidence but should
not take the place of proper medical advice
from a qualifi ed health professional. The
services of a qualifi ed medical practitioner
should be sought before applying the
information to particular circumstances.
Andrology Australia extends an invitation to all to take advantage of the FREE SUBSCRIPTION offer.
Call, fax or email us to register on our mailing list and receive this regular quarterly publication and other items from Andrology Australia.
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In brief
New resources on the Andrology Australia website:
Andrology Australia is pleased to be able to include two new booklets on the website www.andrologyaustralia.org for download.The fi rst booklet, ‘Maintaining your well-being: Information on depression and anxiety for men with prostate cancer and their partners’ was developed by beyondblue: the national depression initiative in partnership with the PCFA. The booklet provides information on common reactions to a diagnosis of prostate cancer, the cancer journey, helpful strategies to deal with prostate cancer, signs of distress, including depression and anxiety, and how to seek help for depression and anxiety. Hard copies are also available from the beyondblue website (www.beyondblue.org.au) or the beyondblue info line (1300 22 46 36).
The second booklet now available to download is the ‘Boys and Puberty: almost everything boys will ever need to know about body changes and other stuff!’. Produced by the Government of Western Australia, Department of Health.
Farewell to Board Member, Professor Doreen Rosenthal AO
Andrology Australia bids a sad farewell to Professor Doreen Rosenthal AO from the Advisory Board. We thank Doreen for her invaluable contribution to the ongoing success of the Andrology Australia program and wish her all the best in her future endeavours.
Professor Doreen Rosenthal AO and
Andrology Australia CEO, Dr Carol Holden
Latest news
PCA3 testing for prostate cancer
A recent study examined whether the level of prostate cancer antigen 3 (PCA3) in the urine following a DRE (Digital Rectal Examination) can be used to help guide the decision to perform a repeat biopsy to confi rm prostate cancer after a raised PSA.
The study suggested possible benefi t of using this urine test in addition to the current PSA test and DRE. The study also explored whether PCA3 could act as an indicator of the clinical stage and aggressiveness of prostate cancer.
Many researchers are looking for new markers of prostate cancer. At this stage, PCA3 is still an experimental test and does not have a place in the routine assessment of prostate disease. There are only a few published studies on PCA3 and diagnostic, cutoff values are not clear and have limited reproducibility. There is no evidence to suggest that the PCA3 test is better than the current testing of PSA and/or DRE in the detection or exclusion of prostate cancer.
While the Internet provides men with access to information about new prostate markers for prostate cancer, PCA3 is not currently approved for use in Australia by the TGA (Therapeutic Goods Administration). While some doctors may offer the technology, as it is not covered by the Medicare Benefi ts Schedule, there may be signifi cant costs to a patient without any rebates being available.
Given the lack of robust evidence, the PCA3 test would potentially raise more doubts than current PSA testing methods and subsequently may increase the rate of biopsies, rather than decrease it.
If you are concerned about prostate cancer, talk to your doctor about the pros and cons of testing using currently available and well-validated methods.
Change of Address
For any future correspondence, please note that our address has changed to:
Andrology AustraliaMonash Institute of Medical ResearchPO Box 5418, Clayton, Victoria, Australia 3168
Issue 32 – Spring 2009
Andrology Australia is supported by a grant from The Australian Government Department of Health and Ageing.
Contents
2 Community education
Supporting the Lions
Australian Prostate Cancer
Website
2 Upcoming events
Merv’s Have a Crack Day
3 Focus on
PSA testing: What everyman
(and health professional)
needs to know
5 Professional education
Practice Nurse Men’s Health
Education
5 Research round-up
Public Knowledge of
Benefi ts of Prostate Cancer
Screening in Europe
6 In brief
6 Latest news
Public Knowledge of Benefi ts of Prostate Cancer Screening in Europe
A recent study1 surveyed 10,228 people across nine European countries to establish the extent of the public’s knowledge of the benefi ts of screening for breast and prostate cancer, to fi nd out whether decisions about testing are likely to be informed. With respect to prostate cancer screening, the study explored whether the public’s knowledge of the benefi ts is realistic, which sources are used for health information, and if the number of times men used the information sources impacts their level of understanding.
The male participants were given a multiple choice question to estimate the number of lives saved by screening after ten years, if 1000 men aged 50 and older had PSA testing every two years. Only 11 per cent of the men surveyed made reasonable estimates (that the number
of prostate cancer deaths prevented for every 1000 men screened was less than or equal to one). The remaining 89 per cent either over-estimated the benefi t or didn’t know. The estimates made by men aged between 50 and 69 were no more correct than those made by men in young age groups.
Family or friends were the most used source of health information, followed by experts (doctors and pharmacists), general media, and lastly health-specifi c resources (including health organisation pamphlets, reference books, health insurance, Internet).
The number of times a man used the sources of information didn’t increase his understanding of the real benefi ts of screening, but was often related to an overestimation of the benefi t.
To ensure men can make informed and rational decisions about whether to have PSA testing, they must be aware of the benefi ts of population-screening (or lack of). An Australian study2 has shown that resources that help patient decision-making used in general practice can increase the doctor’s knowledge and confi dence in discussing testing with men; such as the PSA Decision Card: ‘The Early Detection of Prostate Cancer in General Practice: Supporting Patient Choice’. Available from: www.andrologyaustralia.org/docs/PSAdecisioncard20041007.pdf)
1 Gigerenzer G et al. Public Knowledge of Benefi ts
of Breast and Prostate Cancer Screening in Europe.
JNCI 2009; 101: 1216-1220
2 Steginga S et al. Shared decision-making and
informed choice for the early detection of prostate
cancer in primary care. BJU 2005; 96: 1209-1210
Newsletter of Andrology Australia Australian Centre of Excellence in
Male Reproductive Health
Editor: Sarah Camille
Postal Address:
Andrology Australia Monash Institute of Medical ResearchPO Box 5418, Clayton,Victoria, Australia, 3168
Practice nurses are becoming more widely recognised as an integral part of delivering health information within general practice. Andrology Australia has been working with the Australian Practice Nurses Association (APNA) to identify if a need exists for the development of a men’s health education program developed specifi cally for practice nurses.
A Men’s Health Education Survey was distributed to members of the APNA to determine the information and education needs of practice nurses when engaging men in general practice.
Feedback from the survey showed that the majority of practice nurses had never
undertaken professional education on male reproductive health topics such as erectile dysfunction and prostate disease.
The survey results established a need for the development of a men’s health education program specifi cally targeted toward practice nurses, with 78 per cent of the respondents indicating that they would like further education on men’s health issues within general practice.
To address the need for Practice Nurse Education on men’s health issues, an Andrology Australia Practice Nurse Education Reference Group has been established. The reference group includes practice nurses from across Australia
who have an interest in men’s health, are members of the APNA and have links with their local Division of General Practice.
The reference group will guide and develop a practical education program for practice nurses to deliver current evidence-based men’s health education specifi c to practice nurses across Australia, including rural areas. The initial aim of the reference group is to develop a pilot education program in a format suitable to practice nurse needs and preferred methods of education.
Evaluation of the pilot will help determine areas of improvement for a broader roll-out nation-wide.
The Healthy MaleNewsletter of Andrology Australia – Australian Centre of Excellence in Male Reproductive Health
Public Consultation on draft Clinical Practice Guidelines for the
management of Locally Advanced and Metastatic Prostate CancerThe Australian Cancer Network is inviting public submissions on its draft Clinical Practice Guidelines for the Management of Locally Advanced and Metastatic Prostate Cancer. The guidelines address the management of locally advanced and metastatic prostate cancer including clinical, psychosocial and palliative aspects of the disease.The draft document and directions on how to make a submission can be viewed and downloaded from the ACN website at www.cancer.org.au/clinical_guidelines. Submissions close 5 October 2009.
In response to the results of the overseas trials, Andrology Australia provided its position on the debate about PSA testing for prostate cancer in the last newsletter; with an ‘Andrology Australia Statement on PSA Testing for Prostate Cancer’. Since then, Andrology Australia has received much feedback from men asking “What do the fi ndings mean for me?”
With a lack of conclusive evidence about population-screening, and the recommendation for men to make informed decisions on whether to have a PSA test/DRE (Digital Rectal Examination), it is important that professional societies and health professionals provide a consistent and coherent message on PSA testing to avoid confusion in men considering being tested for prostate cancer.
The 'Focus On' for this edition of The Healthy
Male is PSA testing from the viewpoint of an individual man considering testing, and aims to communicate the current evidence-base to men, the community and health professionals. It translates the evidence-base into information relevant for discussion between a man and his doctor when considering whether to have a PSA test, and lists additional resources that can help to guide the discussion.
We hope this edition of our newsletter helps clarify and guide discussions between men and their doctor in regard to this important health issue.
Professor Rob McLachlan
From
the
Dir
ecto
r
1 Holden CA et al. Men in Australia Telephone Survey (MATeS): a national survey of the reproductive health and concerns of middle-aged and older Australian men. Lancet 2005; 366: 218-224.
2 Andriole GL et al (2009). Mortality Results from a Randomized Prostate-Cancer Screening Trial. N Engl J Med. 360: 1310-1319
3 Schroder FH et al. Screening and Prostate-Cancer Mortality in a Randomized European Study (2009). N Engl J Med. 360 1320-1328 Andriole GL et al (2009). Mortality Results from a
Randomized Prostate-Cancer Screening Trial. N Engl J Med. 360: 1310-1319
4 Barratt A et al. Screening for prostate cancer: explaining new trial results and their implications to patients. MJA 2009; 191: 226-229
5 Smith et al. Evidence-based uncertainty: recent trial results on prostate-specifi c antigen testing and prostate cancer mortality. MJA 2009; 191: 199-200
Prostate cancer testing is a complex and controversial topic of discussion amongst the community, health professionals, professional societies and policy makers. The debate is due to a current lack of evidence on the effectiveness of PSA (prostate specifi c antigen) testing as a population-screening method for reducing deaths of men with prostate cancer.
Even without a current recommendation for population-wide screening for prostate cancer, PSA testing is widespread in Australia: estimates suggest that more than 50 per cent of Australian men over the age of 50 have had a PSA test1.
The anticipated and recently released interim results of two large-scale randomised controlled trials in the USA2 and Europe3 were hoped to provide more defi nite answers on the pros and cons of population-screening for prostate cancer. Unfortunately, their results differed and their interpretation was made diffi cult by the differing study methods. So what do the results mean for men considering having PSA testing and their doctors?
In an effort to interpret the results, two commentary papers with an Australian perspective have been released4 5.
Due to the uncertainty of the results, neither paper recommends population-screening. Instead, men should be informed on the current evidence-base regarding PSA testing, including the benefi ts and limitations of testing, and the common and signifi cant risks of detection and treatment (such as erectile dysfunction and urinary problems). If the well-informed man chooses to have a PSA test, he should be given one. To ensure that men are well informed, both papers call for more evidence and point to the need for more understanding of the benefi ts (in essence, the extent to which deaths can be prevented) versus harms (in essence, the burdens of invasive testing and treatment side-effects) that fl ow from routine PSA testing.
Both papers conclude that the current data suggests that a population-screening program using PSA testing would result in over-diagnosis of low grade tumours with over-treatment resulting in signifi cant and unwarranted side-effects. Furthermore it is suggested that testing should only be applied to men with an anticipated life-expectancy of more than seven years making population-screening inappropriate for many elderly men.
Population-screening for Prostate Cancer using the PSA Test
DISCLAIMER
This newsletter is provided as
an information service.
Information contained in this newsletter is
based on current medical evidence but should
not take the place of proper medical advice
from a qualifi ed health professional. The
services of a qualifi ed medical practitioner
should be sought before applying the
information to particular circumstances.
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In brief
New resources on the Andrology Australia website:
Andrology Australia is pleased to be able to include two new booklets on the website www.andrologyaustralia.org for download.The fi rst booklet, ‘Maintaining your well-being: Information on depression and anxiety for men with prostate cancer and their partners’ was developed by beyondblue: the national depression initiative in partnership with the PCFA. The booklet provides information on common reactions to a diagnosis of prostate cancer, the cancer journey, helpful strategies to deal with prostate cancer, signs of distress, including depression and anxiety, and how to seek help for depression and anxiety. Hard copies are also available from the beyondblue website (www.beyondblue.org.au) or the beyondblue info line (1300 22 46 36).
The second booklet now available to download is the ‘Boys and Puberty: almost everything boys will ever need to know about body changes and other stuff!’. Produced by the Government of Western Australia, Department of Health.
Farewell to Board Member, Professor Doreen Rosenthal AO
Andrology Australia bids a sad farewell to Professor Doreen Rosenthal AO from the Advisory Board. We thank Doreen for her invaluable contribution to the ongoing success of the Andrology Australia program and wish her all the best in her future endeavours.
Professor Doreen Rosenthal AO and
Andrology Australia CEO, Dr Carol Holden
Latest news
PCA3 testing for prostate cancer
A recent study examined whether the level of prostate cancer antigen 3 (PCA3) in the urine following a DRE (Digital Rectal Examination) can be used to help guide the decision to perform a repeat biopsy to confi rm prostate cancer after a raised PSA.
The study suggested possible benefi t of using this urine test in addition to the current PSA test and DRE. The study also explored whether PCA3 could act as an indicator of the clinical stage and aggressiveness of prostate cancer.
Many researchers are looking for new markers of prostate cancer. At this stage, PCA3 is still an experimental test and does not have a place in the routine assessment of prostate disease. There are only a few published studies on PCA3 and diagnostic, cutoff values are not clear and have limited reproducibility. There is no evidence to suggest that the PCA3 test is better than the current testing of PSA and/or DRE in the detection or exclusion of prostate cancer.
While the Internet provides men with access to information about new prostate markers for prostate cancer, PCA3 is not currently approved for use in Australia by the TGA (Therapeutic Goods Administration). While some doctors may offer the technology, as it is not covered by the Medicare Benefi ts Schedule, there may be signifi cant costs to a patient without any rebates being available.
Given the lack of robust evidence, the PCA3 test would potentially raise more doubts than current PSA testing methods and subsequently may increase the rate of biopsies, rather than decrease it.
If you are concerned about prostate cancer, talk to your doctor about the pros and cons of testing using currently available and well-validated methods.
Change of Address
For any future correspondence, please note that our address has changed to:
Andrology AustraliaMonash Institute of Medical ResearchPO Box 5418, Clayton, Victoria, Australia 3168
Issue 32 – Spring 2009
Andrology Australia is supported by a grant from The Australian Government Department of Health and Ageing.
Contents
2 Community education
Supporting the Lions
Australian Prostate Cancer
Website
2 Upcoming events
Merv’s Have a Crack Day
3 Focus on
PSA testing: What everyman
(and health professional)
needs to know
5 Professional education
Practice Nurse Men’s Health
Education
5 Research round-up
Public Knowledge of
Benefi ts of Prostate Cancer
Screening in Europe
6 In brief
6 Latest news
Public Knowledge of Benefi ts of Prostate Cancer Screening in Europe
A recent study1 surveyed 10,228 people across nine European countries to establish the extent of the public’s knowledge of the benefi ts of screening for breast and prostate cancer, to fi nd out whether decisions about testing are likely to be informed. With respect to prostate cancer screening, the study explored whether the public’s knowledge of the benefi ts is realistic, which sources are used for health information, and if the number of times men used the information sources impacts their level of understanding.
The male participants were given a multiple choice question to estimate the number of lives saved by screening after ten years, if 1000 men aged 50 and older had PSA testing every two years. Only 11 per cent of the men surveyed made reasonable estimates (that the number
of prostate cancer deaths prevented for every 1000 men screened was less than or equal to one). The remaining 89 per cent either over-estimated the benefi t or didn’t know. The estimates made by men aged between 50 and 69 were no more correct than those made by men in young age groups.
Family or friends were the most used source of health information, followed by experts (doctors and pharmacists), general media, and lastly health-specifi c resources (including health organisation pamphlets, reference books, health insurance, Internet).
The number of times a man used the sources of information didn’t increase his understanding of the real benefi ts of screening, but was often related to an overestimation of the benefi t.
To ensure men can make informed and rational decisions about whether to have PSA testing, they must be aware of the benefi ts of population-screening (or lack of). An Australian study2 has shown that resources that help patient decision-making used in general practice can increase the doctor’s knowledge and confi dence in discussing testing with men; such as the PSA Decision Card: ‘The Early Detection of Prostate Cancer in General Practice: Supporting Patient Choice’. Available from: www.andrologyaustralia.org/docs/PSAdecisioncard20041007.pdf)
1 Gigerenzer G et al. Public Knowledge of Benefi ts
of Breast and Prostate Cancer Screening in Europe.
JNCI 2009; 101: 1216-1220
2 Steginga S et al. Shared decision-making and
informed choice for the early detection of prostate
cancer in primary care. BJU 2005; 96: 1209-1210
Newsletter of Andrology Australia Australian Centre of Excellence in
Male Reproductive Health
Editor: Sarah Camille
Postal Address:
Andrology Australia Monash Institute of Medical ResearchPO Box 5418, Clayton,Victoria, Australia, 3168
Practice nurses are becoming more widely recognised as an integral part of delivering health information within general practice. Andrology Australia has been working with the Australian Practice Nurses Association (APNA) to identify if a need exists for the development of a men’s health education program developed specifi cally for practice nurses.
A Men’s Health Education Survey was distributed to members of the APNA to determine the information and education needs of practice nurses when engaging men in general practice.
Feedback from the survey showed that the majority of practice nurses had never
undertaken professional education on male reproductive health topics such as erectile dysfunction and prostate disease.
The survey results established a need for the development of a men’s health education program specifi cally targeted toward practice nurses, with 78 per cent of the respondents indicating that they would like further education on men’s health issues within general practice.
To address the need for Practice Nurse Education on men’s health issues, an Andrology Australia Practice Nurse Education Reference Group has been established. The reference group includes practice nurses from across Australia
who have an interest in men’s health, are members of the APNA and have links with their local Division of General Practice.
The reference group will guide and develop a practical education program for practice nurses to deliver current evidence-based men’s health education specifi c to practice nurses across Australia, including rural areas. The initial aim of the reference group is to develop a pilot education program in a format suitable to practice nurse needs and preferred methods of education.
Evaluation of the pilot will help determine areas of improvement for a broader roll-out nation-wide.
The Healthy MaleNewsletter of Andrology Australia – Australian Centre of Excellence in Male Reproductive Health
Public Consultation on draft Clinical Practice Guidelines for the
management of Locally Advanced and Metastatic Prostate CancerThe Australian Cancer Network is inviting public submissions on its draft Clinical Practice Guidelines for the Management of Locally Advanced and Metastatic Prostate Cancer. The guidelines address the management of locally advanced and metastatic prostate cancer including clinical, psychosocial and palliative aspects of the disease.The draft document and directions on how to make a submission can be viewed and downloaded from the ACN website at www.cancer.org.au/clinical_guidelines. Submissions close 5 October 2009.
In response to the results of the overseas trials, Andrology Australia provided its position on the debate about PSA testing for prostate cancer in the last newsletter; with an ‘Andrology Australia Statement on PSA Testing for Prostate Cancer’. Since then, Andrology Australia has received much feedback from men asking “What do the fi ndings mean for me?”
With a lack of conclusive evidence about population-screening, and the recommendation for men to make informed decisions on whether to have a PSA test/DRE (Digital Rectal Examination), it is important that professional societies and health professionals provide a consistent and coherent message on PSA testing to avoid confusion in men considering being tested for prostate cancer.
The 'Focus On' for this edition of The Healthy
Male is PSA testing from the viewpoint of an individual man considering testing, and aims to communicate the current evidence-base to men, the community and health professionals. It translates the evidence-base into information relevant for discussion between a man and his doctor when considering whether to have a PSA test, and lists additional resources that can help to guide the discussion.
We hope this edition of our newsletter helps clarify and guide discussions between men and their doctor in regard to this important health issue.
Professor Rob McLachlanFr
om
the
Dir
ecto
r
1 Holden CA et al. Men in Australia Telephone Survey (MATeS): a national survey of the reproductive health and concerns of middle-aged and older Australian men. Lancet 2005; 366: 218-224.
2 Andriole GL et al (2009). Mortality Results from a Randomized Prostate-Cancer Screening Trial. N Engl J Med. 360: 1310-1319
3 Schroder FH et al. Screening and Prostate-Cancer Mortality in a Randomized European Study (2009). N Engl J Med. 360 1320-1328 Andriole GL et al (2009). Mortality Results from a
Randomized Prostate-Cancer Screening Trial. N Engl J Med. 360: 1310-1319
4 Barratt A et al. Screening for prostate cancer: explaining new trial results and their implications to patients. MJA 2009; 191: 226-229
5 Smith et al. Evidence-based uncertainty: recent trial results on prostate-specifi c antigen testing and prostate cancer mortality. MJA 2009; 191: 199-200
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