New prostate cancer screening guidelines – 2016

Here are the new updated guidelines from Cancer Council Australia and the Prostate Foundation of Australia. High powered document. Let us know what you think. A couple of my thoughts – please comment!

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2016 Prostate Clinical Practice Guidelines on PSA Testing

“Do not offer PSA testing at age 40 years to predict risk of prostate cancer death”
– That is interesting because that was being mooted around?

“Advise men 70 years or older who have been informed of the benefits and harms of testing and who wish to start or continue regular testing that the harms of PSA testing may be greater than the benefits of testing in men of their age”
– So over 70 don’t bother (screening)? Was pretty much the thinking but interesting to say more likely harms than benefit after this age?

“In asymptomatic men interested in undergoing testing for early diagnosis of prostate cancer, digital rectal examination is not recommended as a routine addition to PSA testing in the primary care setting.”
– DRE gonski – unless PSA up and/or symptoms

“Evidence-based recommendation
Offer evidence-based decisional support to men considering whether or not to have a PSA test,
including the opportunity to discuss the benefits and harms of PSA testing before making the decision.”
Grade C
The interesting GP chat at the moment is that we are recommended NOT to bring it up as preventative health – let the patient initiate if they are interested. This is currently being debated and challenged as to whether GPs should be bringing up the topic with their patients. My personal view is this is an interesting “head in the sand” way of dealing with the issue to not talk about it really… But neither do I have a better suggestion!

 

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2 thoughts on “New prostate cancer screening guidelines – 2016

  1. Thanks for posting, Rob.
    The features you’ve highlighted all look reasonable to me.
    The last one, about letting the patient initiate the discussion, has resulted in a lot of discussion–and derision in some quarters. However, I think it makes sense as a pragmatic solution.

    Guideline developers found evidence such that the entirely rational man who is fully informed and has a deep understanding of risk, benefits and harms would choose, on balance, not to screen. However, in the real world, some men would still choose to screen, for various reasons.

    If guidelines advised doctors to raise the issue, it is a whole lot of work and time which, in the perfect rational world, would end with the man choosing not to undergo testing. The man would then quite reasonably wonder why his doctor has just spent the past ten minutes explaining the quite complex issues involved. Time that could have been better spent doing all the other things GPs do. Lots of these discussions add up to a high opportunity cost.

    However, the patient-intiated method targets those men who already have an interest in having a PSA test – after all, it is a very well known screening test which doctors have been recommending for decades. This selects out men who are far more likely than average to end up requesting the test even when given all the information.

    So I guess it is a bit like focussing your efforts on a high-risk group, as we do all the time in medicine. The difference is that the ‘high-risk’ doesn’t refer to the risk of prostate cancer, but the ‘risk’ (i.e. probability) of being the sort of man who would choose to have a PSA test, even after a long discussion about the pros and cons.

    It’s quite a neat middle ground between the extremes of universally discussing PSA or never discussing PSA.

  2. And I see no MRI prior to biospy. I have one bloke who will be coming back following his next PSA to get a request for a MRI as that’s what his previous GP suggested.

    From an AFP paper written by a urologist

    In the future, MRI could be a possible second-line screening tool in men with a mildly elevated PSA and normal DRE, without other risk factors. If the MRI is deemed ‘low-risk’, these men could be followed with serial PSA and DRE rather than biopsy. At present there is insufficient evidence to justify this approach. Until further evidence is available it would be hazardous to omit TRUS biopsy on the basis of MRI.

    http://www.racgp.org.au/afp/2015/april/the-current-status-of-mri-in-%E2%80%A8prostate-cancer/

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