View from a Doctor’s Desk – Dr Lisa Surman

Getting Health Screening Advice from your trusted health professional

Recently, a TV show gave the impression that having a blood test for prostate specific antigen (PSA) and digital rectal examination by a Urologist for prostate cancer was potentially life-saving, and showed a popular presenter having the screening tests done. The specific benefits and harms were not broken down, nor quantified. There was no discussion about the very well documented pros and cons to weigh up before the test and although acknowledging the risk of impotency and incontinence as a consequence of prostate surgery, it was framed as though it was a thing of the past, “The treatments are so vast these days that it’s not as bad as all that, and you’ve got to get checked. You must get checked.”

For men aged 50-69 (without a family history of prostate cancer) the benefit/harm debate for prostate screening using the PSA test is unclear and open to individual interpretation. The decision to have the screening test is a personal one and needs to be done after weighing up the benefits, harms and uncertainties of prostate cancer screening.

If you have a PSA test, you are much more likely to be over-diagnosed and over-treated for prostate cancer than have your life saved from early detection of a nasty form of the disease. This is why the Australian Government does not have a funded, organised prostate screening program and why the Royal Australian College of General Practitioners advises members not to recommend PSA screening to patients.

A digital rectal examination is no longer recommended should a man request screening for prostate cancer after being informed about the risks and benefits of testing.

The National Health and Medical Research Council (NHMRC) advises that a patient who asks a GP about the tests, should be informed of the following information calculated for men in their 60s with no first-degree relatives affected by prostate cancer who have yearly PSA tests.

The stated potential benefits are reassurance if the PSA is normal or very low, early detection and early treatment, hopefully cure. The potential harms are false positive results, with unnecessary biopsy required, false negatives, over-diagnosis and overtreatment resulting in harmful effects without any health benefit.

Potential Benefits:

  • For every 1000 men tested, 2 men will avoid death from prostate cancer before they reach 85 years. This benefit seems greater for men with a strong family history of the disease
  • For every 1000 men tested, 2 men will avoid metastatic prostate cancer before the age of 85 years

Potential Harms:

  • For every 1000 men tested, 28 men will have prostate cancer diagnosed, many of whom would have remained without symptoms for life
  • For every 1000 men treated, 25 men will have surgery or radiation because of uncertainty about which cancers need to be treated. Many would do well without treatment
  • 7 to 10 of these 25 men will develop persistent impotence and/or incontinence and some will develop persisting bowel problems from the treatment
  • For every 2000 men tested, one man will have a serious cardiovascular event, such as a heart attack because of the treatment

The advice delivered in the television series ” The medical checks you have to have” was not in line with current RACGP guidelines nor NHMRC guidelines, which do not recommend routine PSA measures without discussion, nor routine digital rectal examinations as part of screening.

To read the fine detail of the NHMRC recommendations for PSA testing in asymptomatic men, click here.

The RACGP also has a fact sheet to help men make the decision as to whether they will screen for prostate cancer at racgp.org.au and available from your GP.

Information has been developed for men with a family history of prostate cancer that is available on the NSW Health Department’s Centre for Genetics Education website at www.genetics.edu.au/Genetic-conditions-support-groups/prostate-cancer-screening

Andrology Australia ( andrologyaustralia.org) have very detailed, but easily understood fact sheets available with further detail about the statistics and risks of prostate cancer screening.

Dr Lisa Surman, CBD West Medical Centre, Perth, WA

Member of Best Practice Software’s Clinical Leadership Advisory Committee

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