Disagreement over prostate cancer screening guidelines in Oz

Here in the USA, the two main organizations representing the primary care community ( the American College of Physicians [ACP] and the American Academy of Family Physicians [AAFP]) have taken no specific position on early detection and screening for prostate cancer since the ACP issued a now “inactive” guideline in 1997.

By contrast, in Australia, the Royal Australian College of General Practitioners (RACGP) actively discourages screening for prostate cancer in men under 50 years of age, arguing that there is no need for such screening and that the tests could end up doing more harm than good. The 2009 edition of the so-called “Red Book” — a medical guide for physicians developed by the RACGP — suggests that general practitioners in Australia should inform men aged 50 to 70 of years of the risks and benefits of screening for prostate cancer but only give a PSA test if the patient actively requests one. There may be changes to this recommendation in the next edition (expected in the near future). but it has already been made clear that such changes are unlikely to be striking.

Now it would be easy to criticize the RACGP for having a “negative” attitude to screening for prostate cancer. The RACGP’s position is in stark contrast to the recommendations of the major urology and pathology organizations “down under,” both of which have espoused the idea of  baseline PSA test at age 40. But a different way to look at this is to admire the RACGP for taking and expressing a clear position as opposed to avoiding the controversy. Because — let there be no doubt — the use of the PSA test as a tool for the early detection of prostate cancer is becoming more controversial rather than less so, especially in men under 50 and over 70 years of age.

What is sad about all this is that one would think an appropriate working group of physicians representing the primary care, the public health, the oncology, the pathology, the urology, and the radiology communities ought to be able to sit down together to produce a set of sensible consensus guidelines on the appropriate prevention of and screening for prostate cancer. It is clear that there is an ethnic component to risk for prostate cancer. It is clear that there is a genetic component (because of the clear evidence of risk in certain families). And it is clear that a very large percentage of men over the age of 50 are at very low risk for prostate cancer too. Without getting into the details, we should all be able to understand by now that a “one size fits all” approach to the early diagnosis of clinically significant prostate cancer is not going to work. Mass screening of every man over 40 every single year is just not even sensible … and that’s assuming it was doable.

It could take us 20 years to find a better test for clinically significant prostate cancer than the PSA test. Until we have such a test, the right thing to do is to behave like adults and find some common ground. It may not be perfect, but it is better than hanging on for grim life to untenable positions or just ignoring the problem altogether. It is time for the different medical organizations to work together (in Australia and in the USA) as opposed to laying out competing positions like politicians. The fundamental idea here is surely that we should be trying to prevent the delayed diagnosis of progressive forms of prostate cancer while seeking to avoid the unnecessary treatment of men with minimal risk or indolent disease. This does not require the application of rocket science on a societal level.

One Response

  1. Mike your last paragraph hits the mark well. But I will add to it my own opinion …

    It’s time for the medical community to present the facts to the patient and leave the decision to the patient on whether to screen or not to screen and to treat or not to treat. No medical community should withhold such information about PSA testing in the thought that we “over-diagnose” or “over-treat”. At that point they are attempting to “over-protect”. I acknowledge that there is “over-diagnosis” and “over-treatment” to some degree but I also believe that it is due to “under-education”. The medical community should not just sweep the problem under the rug by just skipping a potentially life-saving test.

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