Recently there has been an attack in the media on the newly published Ministry of Health prostate cancer awareness brochures. PCF President Mark von Dadelszen has prepared the following article to explain the Ministry’s and the Government’s actions on this issue over the past 3 years, and also responds to the recent media criticism.
Media Statement – 19th January 2014
Parliamentarians of all parties represented on the Parliamentary Health Select Committee unanimously approved its July 2011 Report on prostate cancer. The Report was unequivocal in its findings:
We heard that many men are reluctant to visit their doctors and often the issues of screening for prostate cancer are not adequately discussed. We are informed that there are many barriers to men seeking advice or care from their GPs …
Delays by men in seeking health care can lead to worse outcomes, particularly where treatable conditions become more advanced before treatment is commenced.
We believe that men should be encouraged to see a doctor for an annual check-up. We understand that the current national guidelines recommend that all men should visit their GPs for an annual cardiovascular “warrant of fitness” from the age of 45 years, or 10 years earlier if they have known cardiovascular risk factors. From the evidence we have heard, this would be an opportune time for men to be encouraged to discuss the pros and cons of prostate cancer screening.
We were concerned by evidence that men are receiving mixed messages about prostate cancer screening. We were told that the advice is often inconsistent, so that comparing advice from different sources can be confusing and unhelpful. We understand how this confusion has arisen, given the uncertainty in the literature regarding the value of screening for prostate cancer. We were also told that a lack of consistent, clear, accessible information for men and their families is an issue regarding screening and every phase of the prostate care and treatment pathway. There is a clear need for GPs and others involved in this field to have available best-practice, evidence-based tools to help their patients to understand the tests for prostate cancer. This evidence should be up-to-date and easily readable, and have a reference to a website that contains more detailed material (a standard video used in some places around the world would help achieve consistency.) Regular updating would be necessary.
The Report made a number of Recommendations relating to those findings and concerns:
We recommend to the Government that the Ministry of Health encourage and promote the case for general practitioners’ providing men with initial consultations about the advantages and disadvantages of screening and treatment for prostate cancer. The initial consultation should take place during the cardiovascular risk assessment which is recommended in the national guidelines, for men at the age of 45, or 10 years earlier for men with known risk factors.
We recommend to the Government that the Ministry of Health encourage and promote the case for men to seek up-to-date evidence-based information from their general practitioners about the advantages and disadvantages of screening and treatment for prostate cancer.
We recommend to the Government that the Ministry of Health encourage general practitioners to advise men with a strong family history of prostate cancer that they have the choice of having their full history noted and then undergoing a clinical examination, PSA testing, and rectal examination from the age of 40.
We recommend to the Government that it ensure that general practitioners have available best-practice, evidence-based tools to help their patients understand the tests available for early detection and treatment of prostate cancer.
We recommend to the Government that it ensure as many men as possible have access to reliable information on the early detection and treatment of prostate cancer.
That 2011 Report’s Recommendations were adopted by the Government. In May 2013 a Ministry of Health Task Force Report was issued, and that set the agenda for the Ministry to address the 2011 Report’s Recommendations.
An 18 December 2013 NZDoctor article, “Ministry gets prostate cancer info badly wrong, say GPs,” was sadly one-sided and incorrect, and it appears to be part of a concerted campaign by those opposed to the Ministry’s strategy to implement the 2011 Parliamentary Health Select Committee Recommendations (it is unlikely to be a coincidence that the NZDoctor article appeared two days after a very similar article in the British Medical Journal, BMJ2013;347doi: http://dx.doi.org/10.1136/bmj.f7537 quoting the same three doctors saying much the same things).
The British Medical Journal and NZDoctor articles quote extensively the views of epidemiologist Associate Professor Cox and GP Dr Jim Vause (chairman of the disestablished Guidelines Group). They both made submissions to the Parliamentary Select Committee on Health, and their opinions were unanimously rejected in the Committee’s 2011 Report recommending that New Zealand men should be better informed about prostate cancer. In May 2013 the Government announced a three year programme to better inform New Zealand men about prostate cancer issues.
Dr Vause was a member of a Task Force that last May unanimously proposed implementation of a prostate cancer information programme. The pamphlets he criticises were produced as a consequence of that Task Force Report. As Dr Lannes Johnson, Clinical Director of Comprehensive Care Ltd (Auckland), has pointed out:
- The pamphlets criticised in the article were designed to facilitate a conversation with patient and doctor, not at all to prepare a patient for national screening. I think the MoH have started the conversation. There is good evidence now that GPs can diagnose PCA early while still curative by making appropriate referrals for biopsy and in many patients diagnosed with PCA (international literature suggests between 40 -50%) can be safely managed (active surveillance) and avoid radical procedures. That way lives are saved and harm is minimised.
In my opinion, those critical of the New Zealand programme to improve men’s information about and understanding of prostate cancer issues show a lamentable lack of faith in the professionalism and intelligence of the New Zealand medical profession, and its GPs in particular. The pamphlets criticised by Associate Professor Cox and Doctors Vause and Corwin suggest that men at appropriate ages should have a discussion with their GPs about prostate cancer. I am more confident than they are that well-informed New Zealand GPs are capable of acting professionally and will give their patients good, objective information. If GPs do so, the cynical predictions of harms arising from “unnecessary” PSA testing will not eventuate. What the critics of the present Ministry programme fail to acknowledge are the consequences for men who have not to date been adequately informed about prostate cancer issues. I, at least, have confidence in the professionalism and integrity of most New Zealand GPs to accept the advice the Ministry will be providing.
Some further points should be borne in mind:
- Prostate Cancer diagnosis and treatment are complex issues, and no short pamphlet can adequately outline all the variable problems. What the Ministry pamphlet does is identify men who should be having a discussion with their GPs about prostate cancer. I think it does that well.
- At this stage the Ministry of Health pamphlet has only been sent to medical professionals. If they choose not to make it publicly available (perhaps because they are awaiting further guidance from the Ministry) they should not at this point be inundated by patients wanting prostate cancer advice.
- The Ministry of Health has other work in progress to provide doctors with improved guidance and decision aids, and that work is likely to be ongoing over the next couple of years.
- The PSA test is by no means perfect as it can produce false positives and negatives, but it is the best test currently available. Similar criticisms can be made of the breast mammograms.
- Much of the criticism of PSA testing overseas comes from countries where medical practice is highly commercialised. I have never heard it suggested that New Zealand doctors promote prostate cancer treatment unnecessarily, but I know of New Zealand GPs who have refused to discuss the issue with patients or to have PSA tests done for New Zealand men.
Mark von Dadelszen
Mobile 027 452 3530