GP pushes back against prostate cancer claims

Filip Vukasin

26/09/2022 4:59:33 PM

Urologists have called for GPs to overhaul prostate cancer screening, stating that not enough men are being tested – but what do the guidelines actually say?

GP Dr Brett Montgomery
GP Dr Brett Montgomery believes it can be difficult for the media to produce stories on overdiagnosis.

Over the weekend, the ABC published an article highlighting a urologist’s call to change Australian prostate cancer screening guidelines.
It was made in the context of a young man who was diagnosed with prostate cancer in his early 40s after having prostate-specific antigen (PSA) testing earlier than recommended by guidelines.
‘There are patients that are angry, that are dying and had a delayed diagnosis,’ Dr Peter Swindle, a urologist who specialises in prostate cancer, told the publication.
‘Unfortunately, the RACGP Red Book, which is the Bible for GPs, is in stark contrast to the NHMRC [National Health and Medical Research Council] testing guidelines.
‘As a result, there is confusion amongst the GP community and GPs don’t know whether they should test men or not.’
However, at least one GP believes these differences have been overstated and the confusion may in fact stem from a misinterpretation, which he conveyed via Twitter.

Dr Brett Montgomery told newsGP that while seemingly at odds on the surface, the two guidelines actually provide very similar advice.
‘I read the article after it was shared in a social media group for GPs,’ Dr Montgomery said. ‘I think [it] significantly misrepresents the contents of the NHMRC guidelines.’
The ABC News article stated that the RACGP Red Book does not recommend PSA testing for prostate screening, but that the NHMRC guidelines do and that it should be offered every two years from age 50–69.
In actuality, the NHMRC guidelines state that for men at average risk of prostate cancer, only those ‘who have been informed of the benefits and harms’ of testing and who ‘decide to undergo regular testing for prostate cancer’ should be offered biennial testing during this window.
Dr Montgomery also points out that a crucial section was missed, which specifically states that the NHMRC guideline ‘does not recommend a population screening program for prostate cancer’ as ‘current evidence does not support such a program’.
‘Unfortunately and understandably, given it is buried on a different page of the guideline, they have missed a critical part … which completely changes the meaning of the bit they have paraphrased,’ he said.
‘In my experience some urologists selectively quote these guidelines to suit their pro-screening agenda, and I suspect this is how the journalists have been misled.’
Australia has three cancer screening programs: cervical, bowel and breast.
According to Cancer Council, prostate cancer is the second most common cancer diagnosed in men in Australia and the third most common cause of cancer death. It is also the most commonly diagnosed cancer in 2022, ahead of melanoma and breast cancer.
However, numerous studies have also shown that prostate cancer screening can lead to harm and its benefits may not outweigh those harms, which include overdiagnosis and overtreatment leading to anxiety, as well as erectile, urinary and bowel dysfunction.
Moreover, for some men, the cancer never progresses and they will die with it, instead of from it.
For RACGP President Adjunct Professor Karen Price, these important considerations GPs need to make when consulting with patients could have been better discussed privately between the professions, rather than being played out in the media, which she said is ‘damaging’.
‘If they had come to us, we could have explained the guidelines aren’t different, there is shared decision making … it speaks to a lack of understanding that we are specialists, that we are a standalone speciality,’ she told newsGP.
‘Having it played out in the media destroys confidence in GPs and also gives a false sense of hope that a blood test provides certainty.’
The RACGP developed a tool in 2015 to help GPs discuss prostate cancer screening with patients, which shows that one life is possibly saved in 1000 men who are screened – but also that those same men are exposed to significant harms.
There was hope in 2014 that new prostate cancer screening guidelines would help give clarity and uniform consensus between GPs and urologists, but as per the recent ABC News article, a divide persists between some.
‘It is really sad that our national broadcaster has produced an article – and an even more problematic TV news piece – that frames GPs and the Red Book guidelines as doing the wrong thing when in fact it is the urologists who are the ones going beyond the guidelines here,’ Dr Montgomery said.
‘I am open to the urologists’ point that the current guidelines could do with an update for our current era, because the now widespread use of MRI helps to reduce harms from PSA testing. This is because MRI reduces the proportion of men with high PSAs who will need a biopsy.
‘But in the meantime, it is still true that neither the Red Book nor the NHMRC guidelines endorse a population screening strategy, despite what these news article/TV news stories say.’
Complicating the issue, Dr Montgomery says, is that it can be difficult to report on overdiagnosis.
‘It’s hard to find anecdotes of overdiagnosis, because at the individual level, no one really knows for sure if they have been overdiagnosed,’ he said.
‘People know they have been diagnosed and treated. And most assume that this has been a good thing – that if their cancer had not been detected through screening, they would have come to much greater harm.
‘This assumption of benefit is a natural thing to do. It must so hard, after a prostatectomy, as you struggle with incontinence and impotence, to ask yourself “was it all for nothing?” It must be so much more comforting to think “this has saved my life – how lucky I am to have had this detected early”.’

Karen-Price-hero.jpgRACGP President Adjunct Professor Karen Price believes no doctor should solely rely on guidelines.
Dr Montgomery highlights that for the media’s part, it is easier and more heartening to write about someone whose life has been saved by unorthodox means than someone who regrets their decision and is suffering embarrassing side effects, such as erectile dysfunction.
This can be complicated by celebrity figures who espouse medical advice against guidelines, such as when Ben Stiller announced his prostate cancer and said he ‘now regularly urges younger people to be checked for the illness’.
‘I am not going to blame Ben Stiller, and the many other men like him, for not having a firm grasp on the results of the randomised controlled trials of prostate cancer screening,’ Dr Montgomery said. ‘That’s not their expertise. They are telling their own stories honestly.
‘But … for every man whose life is saved with prostate cancer screening, there are many more who are suffering significant side effects from treatment of a disease that may never have affected their lives.
‘The evidence tells us that these men exist. And it must be very hard for journalists to find a man to tell this latter sort of anecdote.
‘Many men would not want to share their experience of impotence and incontinence with the public. Many won’t want to publicly ask “what if it was all for nothing?” [and] in fact, I suspect many men do not even want to ask themselves this question in private.’
Meanwhile, Professor Price believes it is an important reminder about the complexity of general practice and the dangers of oversimplification.
‘We use guidelines, but we also speak to colleagues and engage in shared decision making with patients,’ she said.
‘No one should rely solely on guidelines, they are only guidelines and shouldn’t be used tyrannically.
‘Every time a guideline is published, it’s out of date immediately as science evolves.’
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Dr Brian John Mansfield   27/09/2022 7:42:46 AM

There is no comment on radical radiotherapy as an alternative to surgical therapy in this article. This is a pathway to reducing the side effects to radical surgery.

Dr Ian Rivlin   27/09/2022 8:06:24 AM

Any doctor who advocates not getting prostate tested should resign. Society doesn't need medcial dinosaurs. This is the kind of medical irresponsibility I saw in the early 90s when some GPs refused to refer for mammograms in the under 50s. How can it be a bad to know if you have cancer? Tell the patient, let them decide. That's called decency and honesty. Who the devil are these doctors that wish to decide when is appropriate to look for a potentially fatal disease?

Dr Ponnuthurai Paransothy   27/09/2022 11:10:52 AM

Family history of prostate cancer is important too .
If they are concerned , better to check PSA under private fee and ref to Urologist .
This can short out many issues!.

Dr Julian Hadden Fidge   27/09/2022 11:40:08 AM

Another obvious failing by our public health authorities. It's no wonder people don't respect doctors like they used to.
Firstly, screening is not diagnosis.
Secondly, screening is good - cheaper, and with better outcomes
Thirdly, men are entitled to screening for a common cancer.
Fourthly, the same arguments apply to all screening programs.
Fifthly, diagnosis is not performed by GPs. That is done by urologists.
Sixthly, management is not performed by GPs. That is done by urologists.

Every man over 40 years old should be screened annually for prostate cancer with PSA level and free/bound PSA ratio. Elevated results should be repeated to confirm a true result. If it is a true elevation, the patient should be referred to a urologist.

Anything else is liberal intellectual nonsense and indefensible.

Dr Peter James Strickland   27/09/2022 12:22:15 PM

I was astounded when the urologists recommended that screening for prostate cancer was not really necessary except at long intervals of about 2 years. Having had patients and friends die in agony over 50 years from this common male cancer it seemed that there was some hidden agenda or ignorance here. The death rate of prostate cancer is about the same (or more) as per breast cancer ---do we recommend women check their breasts every 2 years for lumps --NO! For men over 50 yo it is absolutely competent to recommend an annual PSA/DRE, and at least give those with an aggressive tumour a chance to get treatment --2 years is too long. I believe it was all the urologist's fault here! A 40 yo getting the cancer is a warning to us all. It reminds me of the chest specialists recommending getting rid of aminophylline from the GP Emergency bag yrs ago --ignorance!

Dr Bella Weisman   27/09/2022 12:50:10 PM

Guidelines r ok But as a GP’s if we trying to talk about it with patients they get angry and abusive and saying “this is my right to get investigated”. And believe me no explanation is good enough to reason with these patients.
Unfortunately prostate ca is on the rise and guide lines should be changed as I know patients in their 20s and 40s diagnosed with prostrate ca.

Dr Mina Salah Gobrial   27/09/2022 1:36:13 PM

I offer PSA to all men over 50 and follow it up with a DRE after explaining the limitations to the psa and potential pitfalls. In 5 years, I have had 6 or 7 men with aggressive high grade prostate cancer detected purely on the DRE. I have also seen a number of men with raised psa who then had malignancy. The one thing I haven't seen is the "overdiagnosis harm". With the advent of mri scanning, biopsies are targeted.
I think the guidelines for not screening are outdated and need radical overhaul.

A.Prof Mark Andrew Gordon Wilson   1/10/2022 10:21:19 AM

An excellence and well balanced response by Dr Montgomery to the recent chatter by journalists and urologists with regard to the recommended use of PSA screening for prostate cancer in Australia. Anecdotal opinion, otherwise known as "the vibe of the thing", is just not good enough .
NHMRC guidelines and Red Book guidelines are in harmony on this point, and are the guidelines for best practice in this country.
The dual problems remain that the current tool available for screening, the PSA, is far from perfect, and that treatment for prostate cancer can often have side effects that need to be be openly and fully discussed during the shared decision making process that must occur between GPs and men between 50 and 69 around the potential utility of the test.
Regular review of screening advise based on best current evidence is important.

Dr Siva Kumar Raju Muppala   1/10/2022 10:56:17 AM

Time to change Guidelines as MRI prostate is useful to avoid over treatment by responsible urologists. I am uncomfortable for not using PSA in my patients.

Dr Penny Wood   2/10/2022 9:23:23 PM

Over screening a population absolutely can cause harm. There has been a trend in certain countries for whole body screening MRI to 'look for lumps'. The outcome of this is increased mortality from surgical complications.

If we're to advocate population screening then we must produce the data showing it saves lives, and that the complications don't vastly outweigh the lives maybe saved.

For sure prostate MRI might be the game changer, or it might not. Show me the data.

Otherwise why not just go ahead with annual abdominal CT for pancreatic cancer?