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Thursday 8 September 2022
Dr Peter Swindle – Urologist Prostate Cancer Specialist
Dr Peter Swindle is a urologist who specialises solely in prostate cancer. His expertise lies in robotic prostatectomy and MRI of the prostate. He has performed over 3500 prostatectomies and works both privately and publicly at Mater Health in South Brisbane.
1. All men should be offered the opportunity to consider PSA testing after a discussion with their GP regarding the risks and benefits of prostate cancer testing. 2. All men 50 – 70 years of age should be offered testing and men with a significant family history of prostate cancer should be offered to start testing at 40 years of age. 3. Testing is performed via a PSA (prostate specific antigen) blood test. 4. Men should be referred for specialist assessment if the PSA is > 3.0 or for men with a positive family history if the PSA > 2.0
Prostate cancer is now the most common cancer in Australian men with 24000 men diagnosed each year. 3500 men die from prostate cancer each year and it is estimated that an Australian male has a 1 in 6 chance of being diagnosed with prostate cancer during their lifetime. It is the second leading cause of cancer death, second only to lung cancer.
In January 2016 the peak medical body in Australia, The National Health and Medical Research Council (NHMRC), released a set of guidelines for prostate cancer testing titled: PSA Testing and Early Management of Test-detected Prostate Cancer: A guideline for health professionals. www.pcfa.org.au/media/612113/PSA-Testing-Guidelines.pdf
The NHMRC is Australia's peak body for developing health advice for the Australian community, health professionals and governments.
There was extensive consultation from many interest groups in establishing the PSA testing guidelines. Representatives from the RACGP (Royal Australian College of General Practitioners) and the RCPA (The Royal College of Pathologists of Australasia) were involved in the development of these guidelines. Numerous other groups including the USANZ (Urological Society of Australia and New Zealand) participated in the development of these guidelines. All interest groups signed off on this document and they were endorsed by the RACGP.
The main recommendations of these guidelines are as follows:
1. These guidelines do not recommend a population-based screening program for prostate cancer 2. Men should be offered the opportunity to consider and discuss the benefits and harms of PSA testing before making the decision whether or not to be tested 3. Further investigation should be offered if the total PSA concentration is greater than 3 ng/ml 4. If a family history is present, further investigation should be offered if the total PSA concentration is greater than 2 ng/ml
The current Ninth Edition of the RACGP produced Red Book was published in 2016 and updated in 2018. The advice to practitioners in the Red Book differs to that of the NHMRC and recommends that practitioners should only “respond to requests for screening on demand ie only if the patient requests testing.”. This has resulted in confusion amongst our general practitioner community. There is a significant difference between offering a man a test if they request it to offering all men a discussion regarding the risks and benefits of testing. The vast majority of men are not aware that they are at risk for prostate cancer. There is unfortunately a misconception amongst men that if they don’t have any symptoms then they are not at risk of prostate cancer. Unfortunately, the take home messages from the NHMRC Prostate Cancer Testing Guidelines have not been actively disseminated amongst medical practitioners throughout Australia.
This issue surrounding mixed messages has been compounded by many pathology providers using outdated age-related PSA reference ranges, as opposed to the values set by the NHMRC. The NHMRC guidelines clearly state that further investigation or referral should occur if the PSA level is greater than 3ng/ml or greater than 2ng/ml for a man with a positive family history. The age-related reference ranges that have been used by most pathology providers throughout Australia are significantly higher than the values set by the NHMRC, and this has caused mass confusion within the primary care community. Furthermore, there are numerous documented cases where these incorrect reference ranges have resulted in a delayed diagnosis as a direct result of a delayed referral.
Research by the Prostate Cancer Foundation Australia (PCFA) has demonstrated 75% of Australians are not aware of the 2016 NHMRC guidelines and the need for regular PSA testing. There is increasing evidence to demonstrate that Australian men are having poor prostate cancer outcomes as a direct result of having a delayed diagnosis. It has been widely demonstrated that the later men are diagnosed with prostate cancer, the worse the outcome, and ultimately the worse overall survival is. Early detection has been proven to be the most effective way to prevent advanced disease and improve survival.
The Prostate Cancer Outcomes Registry for Australian and New Zealand (PCOR), Annual Report 2020, has demonstrated how poorly Australian men are doing with respect to early diagnosis, which then translates to a reduced overall survival. They have demonstrated that there has been an increase in men presenting with late stage disease from 2017 to 2021 from 34% to 38%. They also demonstrated that the median PSA at the time of diagnosis for men with prostate cancer in Australia is 7.3ng/ml.
We have an established set of nationally recognised prostate cancer testing guidelines (2016 NHMRC Guidelines) that recommends further assessment if a man has a PSA > 3.0 or > 2.0 with a positive family history. Despite these guidelines being in place since 2016, the median PSA of Australian men diagnosed with prostate cancer is 7.3. One would expect that if these guidelines had been adhered to, then the median PSA would be closer to 3.0. Clearly Australian men are missing their window of opportunity for cure by being diagnosed with higher PSA values and at later stages of the disease which then translates to a poorer clinical outcome.
There have been adverse perceptions and misinformation surrounding PSA testing in Australia over the last 20 years. The literature that many Australian doctors and peak bodies have based their opinions regarding prostate cancer testing on, is from studies that were commenced in 1993 some 29 years ago. The ERSPC Prostate Cancer Screening Trial did demonstrate that screening for prostate cancer had significant impacts with a reduction in mortality of between 21% and 44% and did lead to a reduction of metastatic disease. The major criticisms of this and similar trials was that the benefits of reduced mortality and decreases metastatic disease were associated with significant harms, such as unnecessary biopsies (biopsies that were performed and prostate cancer not found), over diagnosis (the diagnosis of insignificant cancers that do not pose a threat to the individual during their natural life span) and overtreatment (treating insignificant cancer that does not pose a threat to the individual during their natural life span). In these historical trials the unnecessary biopsy rate was 75%, the overdiagnosis rate 59% and the overtreatment rate 39%. Clearly these were unacceptable parameters. For these reasons prostate cancer mass population-based screening was recommended against by most peak bodies around the world. Unfortunately, the benefits of reduced mortality and reduced metastatic disease were outweighed by the harms of unnecessary biopsies, overdiagnosis and over treatment.
With the introduction of MRI of the prostate into the diagnostic pathway in Australia in 2013 and the Medicare rebate for prostate MRI being approved in July 2018, the diagnostic pathway and clinical outcomes have improved dramatically. In contemporary prostate cancer testing studies, utilising the current guidelines in dedicated prostate cancer testing clinics, we have seen huge advances in the clinical outcomes. We have seen in recent clinical practice studies that the median age at time of diagnosis has been reduced from 69 to 63 and that the median PSA at the time of diagnosis has been reduced from 7.3 to 3.2. We have also seen a significant reduction in the number of unnecessary biopsies from 75% in the ERSPC trial to 21% and a reduction in the diagnosis of insignificant cancers from 59% to 13%. This is also associated with a significant trend in Australia of not treating insignificant cancers and placing these patients on active surveillance. We have seen the overtreatment rate reduce from 39% in the ERSPC to 6% currently in Australia.
Current clinical outcomes, whereby modern clinical practice utilises the recommended prostate cancer testing guidelines, have improved to the extent that the scales have now tipped - the benefits far outweigh the harms. The previously unacceptably high unnecessary biopsy rate, over diagnosis rate and the overtreatment rate have been reduced dramatically and the benefits of reduced mortality and reduced metastatic disease now far outweigh the minimal and reduced harms. Prostate cancer diagnosis and management in 2022 is very different to that 15-20 years ago and the outcomes have vastly improved.
As a result of the recent media stories surrounding prostate cancer in ‘The Australian’, the RACGP has agreed to review the Red Book Guidelines on prostate cancer testing. This will hopefully be associated with widespread education of its members regarding PSA testing. The 2016 NHMRC Prostate Cancer Testing Guidelines are also due for revision. Furthermore, multiple pathology providers in Australia have agreed to change their reference ranges from the outdated age-related PSA reference ranges to those in the NHMRC Guidelines of a PSA of > 3ng/ml or PSA of > 2ng/ml for men with a positive family history. Hopefully as a result of all of these measures, there will be clarity regarding prostate cancer testing in men, which will ultimately result in better clinical outcomes for the most common cancer in Australian men.
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