Prostate cancer: Are GPs stopping too many men from screening?

A war of words has broken out between urologists and the RACGP after a high-profile prostate cancer expert publicly accused GPs of discouraging too many men from being tested.

The debate surrounds a passage in the college’s Red Book of guidelines for preventative health, which says screening, via a prostate-specific antigen (PSA) blood test, is “not recommended” in asymptomatic or low risk men.

Declaring the risks of testing “have not been shown to outweigh the harms” for the group, the guidance goes on to say that GPs have “no obligation” to offer them prostate cancer screening.

It also says the onus is on the individual to request screening, although it stresses that “if after an informed process, perhaps using a decision aid, a man still requests prostate cancer screening, a PSA blood test is acceptable”.

In an interview for ABC news last week, urological surgeon Dr Peter Swindle said the college’s advice to GPs was wrong (link here).

“There are patients that are angry, that are dying and had a delayed diagnosis,” said Dr Swindle, whose Brisbane practice focuses solely on prostate cancer.

He added: “Unfortunately, the RACGP Red Book, which is the Bible for GPs, is in stark contrast to the NHMRC testing guidelines.”

Dr Swindle said the difference between the two was that the NHMRC advice, released in 2016, made no mention of “low risk” patients.

However the guideline did recommend men at “average risk” of prostate cancer should be offered PSA testing every 2 years from age 50 to 69, with informed consent.

“As a result, there is confusion amongst the GP community and GPs don’t know whether they should test men or not,” Dr Swindle said.

It was not the first time the RACGP’s advice on the issue had come under criticism in the media and the Prostate Cancer Foundation of Australia (PCFA) said it wrote to the college in August to request a revision.

The PCFA was awarded $700,000 in the 2022 Federal Budget to review the NHMRC guidelines and said there had also been significant advances since the last update, which had added to the case for regular testing.

“In the six years since the 2016 Guidelines were released, much has changed,” it told the limbic, pointing to the advent of multiparametric MRI as game changer for diagnosis.

The rate of men with low-risk disease undergoing surgery had also declined from 39% to 24% between 2015 and 2018, further supporting the view that over-diagnosis was much less of a concern today, it told the limbic.

“Emerging evidence, evolving standards of care, and access to new technologies have improved the way prostate cancer is diagnosed, treated, and managed, necessitating a review of the recommendations for PSA testing.”

RACGP president Adj. Professor Karen Price said the college’s Red Book was also being reviewed, with a new edition due for release next year.

Nevertheless, she said it was not clear the Red Book was in conflict with the “nuanced” NHMRC guidance, adding it explicitly avoided recommending mass testing.

“But what has got up my nose is the way this has been prosecuted in the media, with GPs being attacked as though we are not doing the right thing when we are,” Professor Price told the limbic.

“What has been presented is a private urologist’s view of the world, a group who see a totally different population to us.”

“We have those conversations on those risks and benefits every day and, while the media never runs articles on the people who have an adverse outcome from screening, we see them a lot.”

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