The treatment of early prostate cancer in Australia has been labelled a scandal
The treatment of early prostate cancer in Australia has been labelled a scandal, with accusations that too many men are undergoing treatment without being properly informed.
Melbourne oncologist Professor Ian Haines told The Medical Republic that it was time for mandatory multidisciplinary assessment and even written informed consent prior to a PSA test, to ensure that inappropriate tests and treatment were not being done.
Professor Haines said there were a disturbing number of patients being encouraged to have surgery, often immediately and with an expensive robot.
“They are often terrified, and their families are terrified that if they don’t have it they’ll die,” he said.
Campaigns such as Blue September and Movember have contributed to the demand for PSA and early interventional treatment, he said.
“And then it sets off a cascade of events that you can’t stop,” Professor Haines said.
If the patient is fully briefed on the harms and benefits of the PSA and still decides to undergo one, they should have the benefit of at least two opinions on their treatment options, he said.
“Ideally from a doctor that doesn’t have a massive vested interest in an incredibly expensive procedure.
“As I say to men, you can have an operation today that increases your chances slightly of living a couple of years longer in your 80s, but you’ll have 30 years of impotence and perhaps incontinence along the way.”
But others have attacked the call to take the decision of prostate cancer treatment away from urologists alone, saying that argument is based on anecdotal cases and uses emotive language.
“It’s inflammatory and inappropriate,” Urological Society of Australia and New Zealand president Professor Mark Frydenberg said.
“The society strongly encourages multidisciplinary care. We strongly recommend patients get all the information they require and if they need information from a radiologist and an oncologist they should get it,” he said.
Figures from the Victorian prostate cancer registry showed that only about half of men diagnosed with prostate cancer in a year were getting surgery, but all were diagnosed by a urologist, Professor Frydenberg said.
“[Professor Haines] is suggesting that we are just biopsying and treating everybody, pushing everybody into expensive robotic surgery […] it’s not backed up by a shred of data.”
While Professor Frydenberg said he did agree that patients were not always adequately educated about the benefits and risks of the PSA test, it was no more in need of formal consent than any other medical test with uncertain benefit.
“There needs to be better education of patients about the test, not just sticking it onto the end of a blood or sugar test,” he said.
“But we do extra blood tests and MRI scans now, so we’re actually much more selective about who we send to biopsy, and biopsy rates have been steadily dropping in Australia for the past few years.”
Ultimately, RCT evidence showed a mortality benefit in the right age group, and the NHMRC recommendation to test was endorsed by the RACGP, the Urological Society and others, Professor Frydenberg said.