The prostate cancer testing dilemma – help is finally on its way

3 June 2015

ROSEMARY MINTO calls for nurses to be informed and take a lead in educating men and their whānau about prostate cancer. The NP, who sadly lost her own father to the most commonly diagnosed cancer in men, is a member of the Prostate Cancer Working Group, which is soon to release a long-awaited best practice pathway for prostate cancer testing and management.

My dad died of metastatic prostate cancer, which shocked me for two reasons.

The first was that I didn’t know he had been diagnosed with prostate cancer in the first place. The second was because I was told by family that he'd made an informed choice, when first advised of his rising PSA (prostate-specific antigen) levels, to disregard conventional follow-up in favour of alternative treatment.

Was his choice informed? I will never know because I wasn’t involved in that initial decision-making and also 20 years ago there were no clear guidelines on testing, screening or ongoing management for prostate cancer. The sad thing is that today New Zealand men face similar choices and we still don't have clear best practice guidelines for prostate cancer testing or for the management of metastatic disease. That is, until now … but more about that further on.

Prostate cancer was for many years the poor relation when compared with national awareness campaigns for breast and cervical cancers, which is not good considering it is the most commonly diagnosed cancer in men and the third most common cause of cancer deaths in New Zealand adult males. Recent research also shows it kills Māori men at a higher rate than European men, second only to lung cancer.

For years general practitioners have been calling for clear recommendations on whether or not to test or screen for prostate cancer and for these recommendations to be backed by resources they can discuss and share with patients and their families.

Prostate cancer screening is a topic guaranteed to get GPs arguing vociferously for and against, with both sides quoting evidence to back up their claims – which just goes to prove that you can twist data any way you want to prove a point!

Unfortunately for health professionals and patients, the evidence around the benefits or lack thereof of population-based screening remains murky and open to interpretation, with findings from two of the larger more recent trials being somewhat contradictory. (Last year the University of Auckland also released their excellent Midlands prostate cancer study, by Waikato-based Professor Ross Lawrenson and colleagues, which provides New Zealand-based research.)

In 2013, in response to the calls for greater clarity, the Ministry of Health set up the Prostate Cancer Awareness and Quality Improvement Programme (AQIP) action plan based on recommendations from a Prostate Cancer Taskforce*. As part of the AQIP the Ministry commissioned a National Prostate Cancer Working Group (of which I’m a member) to guide the implementation of the improvement programme. The group have developed the Prostate Cancer Management and Referral Guidance which will help primary care practitioners provide men and their whānau with consistent information on prostate cancer testing and treatment. The guidance will likely be published in September this year.

So where are nurses in this conversation? Within the prostate cancer working groups and subgroups are three nurse members, with other members including medical specialists, GPs, academics and lay people.

Until now, nurses have largely been absent from the debates around prostate cancer. I suspect that while this is mostly because they have not had an active role in diagnosis, it is also partially because of the lack of clarity around screening. 

If you consider the extensive role that practice nurses have in cervical and breast cancer screening, then it makes sense for nurses to be better informed so they can take a lead in educating men and their whānau about prostate cancer.

With the newly developed guidelines being available shortly to providers, and the planned development of a software decision support tool for patient management systems in general practice, nurses will have access to tools to help men make informed choices, in particular about prostate cancer testing.

It is a pragmatic approach developed by New Zealand doctors, nurses and experts, based on consensus and the best evidence we currently have.

I would recommend that ALL nurses be well informed now on the available evidence, information and guidelines work, rather than waiting for the new tools, so they are prepared and competent to answer men’s questions. This information is readily available on the Ministry of Health’s website (see below).

Don’t be a bystander in your man’s healthcare decisions – be informed and actively participate.

*The taskforce concluded that there was currently no good quality evidence that routine prostate specific antigen (PSA) testing can effectively reduce prostate cancer deaths. So population-based screening for prostate cancer is not recommended in New Zealand. (Note added by editor)

REFERENCES:

Lawrenson, R., Brown, C., Obertova, Z., Lao, C., and Conaglen, H. (2014). The final report: the Midlands prostate cancer study: understanding the pathways of care for men with localised prostate cancer. Retrieved from https://www.fmhs.auckland.ac.nz/en/som/about/clinical-schools/waikato/research/cancer-research/prostate-cancer-research/cancer/publications.html

Ministry of Health. (2013). Prostate Cancer Awareness and Quality Improvement Programme: Improving outcomes for men with prostate cancer. Wellington: Ministry of Health. http://www.health.govt.nz/publication/prostate-cancer-awareness-and-quality-improvement-programme-improving-outcomes-men-prostate-cancer

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