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PSA Testing for Prostate Cancer in Asymptomatic Men: Information for Health Practitioners submission

ID: 
7
This submission reflects the views of
Organisation Name: 
Department of Health, Victoria
Personal Details
Specific Questions
1. What are the potential benefits of PSA testing?: 

No specific comment.

2. What are the potential harms of PSA testing?: 

No specific comment.

3. How frequent are these benefits and harms?: 

Consideration could be given to combining the sections on Overdiagnosis and Overtreatment to improve clarity, although it is noted that these categories are both recognised terms in screening practice for describing potential harms.

4. What research has been done to study the effectiveness of PSA testing for prostate cancer?: 

No specific comment.

5. Does PSA testing in asymptomatic men reduce their risk of dying from prostate cancer?: 

Consider use of the term ‘prostate-specific mortality’ as this information is intended for a health professional audience, likely GPs.

Does this section accurately represent the evidence base, in other words, is the overall conclusion that the evidence is inconsistent accurately representing the evidence base?  It may be more accurate to state that overall, the evidence suggests there is no reduction in prostate-specific or all-cause mortality, with one important trial that found otherwise, rather than paint the evidence picture as simply inconsistent.

6. Does PSA testing in asymptomatic men reduce their overall risk of dying?: 

Consider use of the term ‘all-cause mortality’ as this information is intended for a health professional audience, likely GPs.

Consider moving this question up so it is the first question on page two, in other words, it is a more important question for whether to screen asymptomatic men with PSA than the question of prostate-specific mortality.  The hierarchy of importance in effect on mortality is evident when one considers that if a screening test for a given disease reduced disease-specific mortality successfully, but at the cost of increased overall mortality (through deaths from complications of the ensuing treatment people received), it would not be acceptable or suitable.

7. Does PSA testing in asymptomatic men reduce their risk of having metastases present at diagnosis of prostate cancer?: 

No specific comment.

8. Does PSA testing in asymptomatic men affect the quality of life of men who are diagnosed with prostate cancer?: 

No specific comment.

9. What is a PSA test?: 

No specific comment.

10. How accurate is a PSA test?: 

No specific comment.

11. Are there any other screening tests available for prostate cancer?: 

No specific comment.

12. How can men prepare for a PSA test?: 

No specific comment.

13. What are normal and abnormal PSA test results?: 

No specific comment.

14. What happens if a man receives a normal PSA test result?: 

No specific comment.

15. What happens if a man receives an abnormal PSA test result?: 

This is an important section and in line with comments later regarding use of facts and references, would benefit from more numerical data.  The section should include actual rates of the various complications listed, especially and for example the rate of local and systemic infection post-biopsy.  The audience would expect to hear what the rate(s) is/are, not simply that infection is possible, which is arguably always the case with any invasive procedure.

16. If a man receives a diagnosis of prostate cancer after an abnormal PSA test, what choices does he have?: 

No specific comment.

17. If a man decides not to have a PSA test what risks should he and his family be aware of?: 

On the balance of evidence, use of the PSA test for screening asymptomatic men is not recommended.  Given this current public health and policy environment, a man that is asymptomatic who chooses not to be screened (chooses not to have a PSA test) is arguably taking the least risky course of action.  So this section continues to need to be very carefully worded to avoid giving men who make this choice in line with current RACGP policy the impression they are out of step, or incurring significant risks.

Perhaps alter the third line to read ‘…he may miss potential benefits…’.

General Comments
18. Considering the Information Document is for Health Practitioners, do you have any other comments?: 

1.       Giving guidance on whether to screen asymptomatic men for prostate cancer using PSA testing

The evidence presented does not show an overall mortality benefit from PSA testing in asymptomatic men, and does not show a prostate-cancer specific mortality benefit, as well conducted systematic reviews have concluded found, including those assessed in this overview. This NHMRC work has identified only one good trial that might show this benefit – in the view of this department this does not constitute sufficient evidence of benefit, and indeed has been characterised as inconsistent evidence in the document. 

Testing asymptomatic men with PSA is screening.  In the case of prostate cancer, screening should not be recommended in the absence of good quality evidence of mortality benefit, as well as other criteria being met, given the evidence of substantial harms that can arise from screening.  The absence of good quality evidence of benefit is in itself sufficient to conclude that, in general, screening should not be recommended, and this is the policy position adopted in most parts of the world including by theRoyalAustralianCollegeof General Practitioners.  Health practitioners will expect a document such as this to give a recommendation overall on whether screening is worthwhile as a public health intervention.  The absence of this recommendation or overview perspective detracts from the credibility of the document, as it does not provide that which practitioners are likely to desire from it  – guidance.

In summary, the Information document is concerned with the merits of screening for prostate cancer, although this is presented as the merits of PSA testing.  The document should advise health practitioners whether screening certain age groups of men is, overall, a worthwhile endeavour, in other words on balance whether screening should be undertaken.  Even though the assessment of merits of screening against criteria such as those used by the United Kingdom National Screening Committee is a wider endeavour, the apparent absence of this wider work as part of this process is not required in this case as the primary hurdle of good evidence of mortality benefit has not been met.

2.       Audience and language

The largest subset of the potential health professional audience is likely to be general practitioners (GPs).  In order to be of interest to GPs and to be credible in the eyes of GPs, it needs to use language and scientific facts and figures that meet the expertise and expectations of GPs, and needs to be referenced appropriately.  In relation to this comment, the following could be considered:

  • use of tables and where possible rates to represent numerical data;
  • use of medical terminology around mortality (all-cause mortality, prostate-cancer specific mortality);
  • linking all statements of scientific fact to aVancouveror other-styled reference in a separate section at the end of the document.

Page reviewed: 4 March, 2014