View Article PDF

For decades, the optimal management of men with prostate cancer has divided the international urological community. Prostate cancer remains the most expensive cancer in the New Zealand healthcare system, the most commonly diagnosed with around 4,000 new cases per year, and a common cause of death. Ultimately, the vast variability in clinical expression and progression of prostate cancer as a disease, combined with the potential morbidity associated with treatment, has proven to be a conundrum to which the unequivocal truth is yet to be uncovered.

The morale among clinicians and scientists was high when the prostate specific antigen (PSA) blood test was discovered in 1979 and urologists worldwide started using it as a “test for prostate cancer”. However, PSA turned out not to be the panacea that we were expecting for screening and diagnosing prostate cancer. Features of a so-called ideal screening test are often cited:

• The diagnostic/screening test should have a high sensitivity and specificity.

• The disease being screened for should have a high prevalence and significant morbidity and/or mortality and also have a long latent (pre-clinical) phase.

• Treatment for the disease should be available and curative, or significantly palliative. Side-effects of diagnosis and treatment should be minimal.

• Cost-benefit ratio of screening and treatment should be favorable, ie, minimal cost, maximal benefit, therefore high value.

In the topical article authored by Matti and Zargar-Shoshtari,1 the authors clearly state the evidence around prostate cancer screening has shifted. We in New Zealand need to rethink our advice in this area. A national prostate cancer screening programme would require considerable resources, standard simple advice and access to diagnostic investigations.

Population-based screening is where a screening test is offered systematically to all individuals in a defined target group within a framework of agreed policy, protocols, quality management, monitoring and evaluated through a quality improvement framework.2 While the European Association of Urology (EAU) is currently driving the planned implementation of coordinated prostate cancer screening programmes in European countries,3 establishing such a programme in other countries including New Zealand, will require the development of individualised models based on local health systems, improved resources and infrastructure in contemporary diagnostics and treatments.

Pensive planning will be required to construct the optimal prostate cancer screening cascade so that we do not miss the mark, as the line between benefit and harm to our patients is indeed a thin one. The first area of refinement is determining who the population is to be screened by using risk stratification; in the case of prostate cancer this is based primarily on age and family history and ethnicity. There is good international evidence that such a systematic screening for prostate cancer may reduce sociodemographic health inequity.4,5 This is a lucrative prospect to us as urologists in New Zealand, where we are still trying to map out the exact interplay of factors that contribute to Māori men having a higher prostate cancer mortality but a lower diagnosis rate.6

In fact, Māori men have the highest mortality rate from prostate cancer among all indigenous New Zealand populations. In an attempt to explain this, various factors have been studied; these include among others socioeconomic disparities, demographics, access to healthcare, diet, body mass index and differences in treatment modalities.7,8 Regrettably, current research findings still leave us with a significant and unexplained gap in outcomes and survival in Māori men with prostate cancer when compared to their fellow New Zealanders of European descent. When designing a nationwide, population-based screening programme for prostate cancer it would be imperative to ensure that not only the known inequities are factored into the screening cascade, but also that the as yet unexplored causative factors in this population group—one of which being genetic risk factors—are adequately investigated through prudently designed genetic research studies.9

If the threshold for prostate cancer screening is met, the next step of the screening cascade is the digital rectal exam (DRE) and PSA test, the optimal frequency of which is to be determined. Currently DRE and PSA testing in asymptomatic men in New Zealand is sporadic, dependent on the patient or GP instigating this investigation. Māori men may have a cultural barrier to such a pathway due to the low tolerance of a DRE. Based on this current New Zealand case finding scenario, there is an unequal testing regimen in our population. A well supported, standardised screening programme with a clear message to patients and GPs, plus accurately collected data, would improve the prostate cancer diagnosis to all men, including those men not currently tested.

A prostate biopsy is required for a diagnosis of prostate cancer. Outpatient local anaesthetic trans rectal biopsy is a standard of care. Trans-perineal prostate biopsy under general local anaesthetic is increasingly being undertaken due to improved diagnostic accuracy and reduced sepsis.10,11

In recent years an additional aid to the diagnosis of prostate cancer is multi-parametric Magnetic Resonance Imaging (mpMRI).12 MRI scanning is not consistently available in New Zealand due to cost and availability. MRI can create images that show the relative presence of prostate cancer, using a PI-RADS scale 1–5 (Prostate Imaging, Reporting and Data System). Pi-RADS 1–3 low risk 10–20% likelihood cancer, PI-RADS 4,5 60–90% risk, and allowing a targeted biopsy. A standard of care in the NHS is an MRI prior to consideration of a prostate biopsy, yet this investigation is only undertaken in a small number of men before biopsy in New Zealand. Up to 40% of men may delay or avoid a prostate biopsy with a negative MRI.12The ultimate aim of clinical workup which will follow a positive test is to determine the aggressiveness and extent of disease. In New Zealand approximately 40% of men have low risk of disease, the majority undergoing active surveillance to lower the risk of treatment-related morbidity. Surgical treatment is the commonest treatment in intermediate and high-risk localised disease, with the majority as an open retropubic procedure. Internationally, robotic prostatectomy is the standard of care with over 60% of men in Australia and over 80% of men treated this way in the NHS. Robotic prostate surgery is not available in the public system in New Zealand.

While we as clinicians often find it challenging to navigate the ever-changing landscape of this disease with many aspects still uncharted, we should not lose sight of the thousands of men who are cured of prostate cancer every year through early detection, efficient multidisciplinary decision-making and appropriate locally delivered treatment.

Comprehensive cancer registries play an important role in determining the value of cancer treatment . The New Zealand National Prostate Cancer Outcomes Registry, funded by a Movember grant, is helping to understand and improve the outcomes of men diagnosed with prostate cancer. Prostate Cancer Outcomes Australia and New Zealand (PCORANZ) was instigated in 2016 and is currently collecting demographic, diagnostic, treatment and patient outcomes.13 Over 90% of New Zealand public hospital patient data is collected and now being reported back to clinicians and hospitals in standard six-monthly reports. These reports drive quality improvement and may highlight variance in care.

While frameworks exist to deal with the general design and implementation of national screening programmes,14 addressing the elephant in the room of who will foot the bill in New Zealand for this grand plan is a more challenging task. Apart from the cost of increased volumes of PSA-tests, the subsequent impact on resources, including human resources, will need to be factored in. However, in monetary terms it is simply a matter of investing in modestly increased costs at the early stages of the cancer journey in order to avoid the eye-watering (alternative budget-crippling) costs often associated with the treatment of the advanced stages of prostate cancer. PSA tests are relatively inexpensive even if they need to be repeated numerous times in a patient’s lifetime. Even if combined with the costs of a multi-parametric MRI scan it is still considerably cheaper than the treatment of advanced and metastatic disease, the latter of which only marginally improves survival.15 While the costs of robot-assisted radical prostatectomy rarely exceed US$17,000 per patient, the costs for the management of patients with metastatic, castration-resistant prostate cancer can be up to US$350,000 during a patient’s lifetime.16 In addition to the cost saving associated with early detection of prostate cancer, the surgical outcomes and post-treatment quality of life and length of life of our patients are superior when their tumours are treated in the earlier stages of the disease.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Amir Zarrabi, TD Scott Chair in Urology, University of Otago, Dunedin; Stephen Mark, Consultant Urologist, Christchurch Hospital, Christchurch.

Acknowledgements

Correspondence

Stephen Mark, Consultant Urologist, Christchurch Hospital, Christchurch.

Correspondence Email

stephen@urology.co.nz

Competing Interests

Nil.

1. Matti B, Zargar-Shoshtari K. Prostate cancer screening in New Zealand: lessons from the past to shape the future in the light of changing evidence. N Z Med J 2020; 133(1523):87–95.

2. Australian Government Department of Health Standing Committee on Screening. Population based screening framework 2018. http://www.health.gov.au/resources/publications/population-based-screening-framework

3. Van Poppel H, Chapple C, Montorsi F, et al. Policy paper on PSA screening for prostate cancer: Has the time come to reconsider structured population-based PSA screening for prostate cancer? European Association of Urology 2019. http://uroweb.org/epad19-european-psa-screening-programme-is-on-its-way-part-2/

4. Shieh Y, Eklund M, Sawaya GF, Black WC, Kramer BS, Esserman LJ. Population-based screening for cancer: hope and hype. Nat Rev Clin Oncol 2016; 13(9):550–565.

5. Hugosson J, Godtman RA, Carlson SV, et al. Eighteen-year follow-up of the Göteborg Randomized Population-based Prostate Cancer Screening Trial: effect of sociodemographic variables on participation, prostate cancer incidence and mortality. Scand J Urol 2018 Feb; 52(1):27–37.

6. Blair V, Kahokehr A, Sammour T. Cancer in Māori: lessons from prostate, colorectal and gastric cancer and progress in hereditary stomach cancer in New Zealand. ANZ J Surg 2013; 83(1–2):42–48.

7. Obortova Z, Lawrenson R, Scott N, et al. Treatment modalities for Māori and New Zealand European men with localised prostate cancer. Int J Clin Oncol 2015; 20(4):814–820.

8. Obortova Z, Scott N, Brown C, et al. Survival disparities between Māori and non-Māori men with prostate cancer in New Zealand. BJU Int 2015; 115(Supplement 5), 24–30.

9. Lea RA, Hall D, Chambers GK, Griffiths LR. The New Zealand Maori Population as a Candidate for Admixture Gene Mapping. ASHG Annual Meeting 2006, Abstract 1521.

10. Grummet JP, Weerakoon M, Huang S, Lawrentschuk N, Frydenberg M, Moon DA, O’Reilly M, Murphy D. Sepsis and ‘superbugs’: should we favour the transperineal over the transrectal approach for prostate biopsy?. BJU Int. 2014 Sep; 114(3):384–8.

11. Hübner N, Shariat S, Remzi M, Prostate biopsy: guidelines and evidence. Curr Opin Urol. 2018 Jul; 28(4):354–359.

12. Ahmed H, Ahmed El-Shater Bosaily, Brown L, et al and the PROMIS group. Diagnostic accuracy of multi-parametric MRI and TRUS biopsy in prostate cancer (PROMIS): a paired validating confirmatory study. The Lancet 2017; 389:815–822.

13. Evans SM, Nag N, Order D, Brooks A, Millar JL, Moretti KL, Pryor D, Skala M, McNeil JJ. Development of an International Prostate Cancer Outcomes Registry BJUI Int 2016; 117 Suppl 4:60–67.

14. Pedersen JH, Ashraf H. Implementation and organization of lung cancer screening. Ann Transl Med 2016; 4(8):152.

15. Cornford P, Bellmunt J, Bolla M, et al. EAU-ESTRO-SIOG Guidelines on prostate cancer. Part II: Treatment of relapsing, metastatic and castration-resistant prostate cancer. Eur Urol 2017; 71(4):630–642.

16. Van Poppel H, Bjartell A, Bossi A. EAU White paper on prostate cancer. April 2020 http://uroweb.org/wp-content/uploads/EAU_PCa-WhitePaper-FINAL-VERSION.pdf

Contact diana@nzma.org.nz
for the PDF of this article

View Article PDF

For decades, the optimal management of men with prostate cancer has divided the international urological community. Prostate cancer remains the most expensive cancer in the New Zealand healthcare system, the most commonly diagnosed with around 4,000 new cases per year, and a common cause of death. Ultimately, the vast variability in clinical expression and progression of prostate cancer as a disease, combined with the potential morbidity associated with treatment, has proven to be a conundrum to which the unequivocal truth is yet to be uncovered.

The morale among clinicians and scientists was high when the prostate specific antigen (PSA) blood test was discovered in 1979 and urologists worldwide started using it as a “test for prostate cancer”. However, PSA turned out not to be the panacea that we were expecting for screening and diagnosing prostate cancer. Features of a so-called ideal screening test are often cited:

• The diagnostic/screening test should have a high sensitivity and specificity.

• The disease being screened for should have a high prevalence and significant morbidity and/or mortality and also have a long latent (pre-clinical) phase.

• Treatment for the disease should be available and curative, or significantly palliative. Side-effects of diagnosis and treatment should be minimal.

• Cost-benefit ratio of screening and treatment should be favorable, ie, minimal cost, maximal benefit, therefore high value.

In the topical article authored by Matti and Zargar-Shoshtari,1 the authors clearly state the evidence around prostate cancer screening has shifted. We in New Zealand need to rethink our advice in this area. A national prostate cancer screening programme would require considerable resources, standard simple advice and access to diagnostic investigations.

Population-based screening is where a screening test is offered systematically to all individuals in a defined target group within a framework of agreed policy, protocols, quality management, monitoring and evaluated through a quality improvement framework.2 While the European Association of Urology (EAU) is currently driving the planned implementation of coordinated prostate cancer screening programmes in European countries,3 establishing such a programme in other countries including New Zealand, will require the development of individualised models based on local health systems, improved resources and infrastructure in contemporary diagnostics and treatments.

Pensive planning will be required to construct the optimal prostate cancer screening cascade so that we do not miss the mark, as the line between benefit and harm to our patients is indeed a thin one. The first area of refinement is determining who the population is to be screened by using risk stratification; in the case of prostate cancer this is based primarily on age and family history and ethnicity. There is good international evidence that such a systematic screening for prostate cancer may reduce sociodemographic health inequity.4,5 This is a lucrative prospect to us as urologists in New Zealand, where we are still trying to map out the exact interplay of factors that contribute to Māori men having a higher prostate cancer mortality but a lower diagnosis rate.6

In fact, Māori men have the highest mortality rate from prostate cancer among all indigenous New Zealand populations. In an attempt to explain this, various factors have been studied; these include among others socioeconomic disparities, demographics, access to healthcare, diet, body mass index and differences in treatment modalities.7,8 Regrettably, current research findings still leave us with a significant and unexplained gap in outcomes and survival in Māori men with prostate cancer when compared to their fellow New Zealanders of European descent. When designing a nationwide, population-based screening programme for prostate cancer it would be imperative to ensure that not only the known inequities are factored into the screening cascade, but also that the as yet unexplored causative factors in this population group—one of which being genetic risk factors—are adequately investigated through prudently designed genetic research studies.9

If the threshold for prostate cancer screening is met, the next step of the screening cascade is the digital rectal exam (DRE) and PSA test, the optimal frequency of which is to be determined. Currently DRE and PSA testing in asymptomatic men in New Zealand is sporadic, dependent on the patient or GP instigating this investigation. Māori men may have a cultural barrier to such a pathway due to the low tolerance of a DRE. Based on this current New Zealand case finding scenario, there is an unequal testing regimen in our population. A well supported, standardised screening programme with a clear message to patients and GPs, plus accurately collected data, would improve the prostate cancer diagnosis to all men, including those men not currently tested.

A prostate biopsy is required for a diagnosis of prostate cancer. Outpatient local anaesthetic trans rectal biopsy is a standard of care. Trans-perineal prostate biopsy under general local anaesthetic is increasingly being undertaken due to improved diagnostic accuracy and reduced sepsis.10,11

In recent years an additional aid to the diagnosis of prostate cancer is multi-parametric Magnetic Resonance Imaging (mpMRI).12 MRI scanning is not consistently available in New Zealand due to cost and availability. MRI can create images that show the relative presence of prostate cancer, using a PI-RADS scale 1–5 (Prostate Imaging, Reporting and Data System). Pi-RADS 1–3 low risk 10–20% likelihood cancer, PI-RADS 4,5 60–90% risk, and allowing a targeted biopsy. A standard of care in the NHS is an MRI prior to consideration of a prostate biopsy, yet this investigation is only undertaken in a small number of men before biopsy in New Zealand. Up to 40% of men may delay or avoid a prostate biopsy with a negative MRI.12The ultimate aim of clinical workup which will follow a positive test is to determine the aggressiveness and extent of disease. In New Zealand approximately 40% of men have low risk of disease, the majority undergoing active surveillance to lower the risk of treatment-related morbidity. Surgical treatment is the commonest treatment in intermediate and high-risk localised disease, with the majority as an open retropubic procedure. Internationally, robotic prostatectomy is the standard of care with over 60% of men in Australia and over 80% of men treated this way in the NHS. Robotic prostate surgery is not available in the public system in New Zealand.

While we as clinicians often find it challenging to navigate the ever-changing landscape of this disease with many aspects still uncharted, we should not lose sight of the thousands of men who are cured of prostate cancer every year through early detection, efficient multidisciplinary decision-making and appropriate locally delivered treatment.

Comprehensive cancer registries play an important role in determining the value of cancer treatment . The New Zealand National Prostate Cancer Outcomes Registry, funded by a Movember grant, is helping to understand and improve the outcomes of men diagnosed with prostate cancer. Prostate Cancer Outcomes Australia and New Zealand (PCORANZ) was instigated in 2016 and is currently collecting demographic, diagnostic, treatment and patient outcomes.13 Over 90% of New Zealand public hospital patient data is collected and now being reported back to clinicians and hospitals in standard six-monthly reports. These reports drive quality improvement and may highlight variance in care.

While frameworks exist to deal with the general design and implementation of national screening programmes,14 addressing the elephant in the room of who will foot the bill in New Zealand for this grand plan is a more challenging task. Apart from the cost of increased volumes of PSA-tests, the subsequent impact on resources, including human resources, will need to be factored in. However, in monetary terms it is simply a matter of investing in modestly increased costs at the early stages of the cancer journey in order to avoid the eye-watering (alternative budget-crippling) costs often associated with the treatment of the advanced stages of prostate cancer. PSA tests are relatively inexpensive even if they need to be repeated numerous times in a patient’s lifetime. Even if combined with the costs of a multi-parametric MRI scan it is still considerably cheaper than the treatment of advanced and metastatic disease, the latter of which only marginally improves survival.15 While the costs of robot-assisted radical prostatectomy rarely exceed US$17,000 per patient, the costs for the management of patients with metastatic, castration-resistant prostate cancer can be up to US$350,000 during a patient’s lifetime.16 In addition to the cost saving associated with early detection of prostate cancer, the surgical outcomes and post-treatment quality of life and length of life of our patients are superior when their tumours are treated in the earlier stages of the disease.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Amir Zarrabi, TD Scott Chair in Urology, University of Otago, Dunedin; Stephen Mark, Consultant Urologist, Christchurch Hospital, Christchurch.

Acknowledgements

Correspondence

Stephen Mark, Consultant Urologist, Christchurch Hospital, Christchurch.

Correspondence Email

stephen@urology.co.nz

Competing Interests

Nil.

1. Matti B, Zargar-Shoshtari K. Prostate cancer screening in New Zealand: lessons from the past to shape the future in the light of changing evidence. N Z Med J 2020; 133(1523):87–95.

2. Australian Government Department of Health Standing Committee on Screening. Population based screening framework 2018. http://www.health.gov.au/resources/publications/population-based-screening-framework

3. Van Poppel H, Chapple C, Montorsi F, et al. Policy paper on PSA screening for prostate cancer: Has the time come to reconsider structured population-based PSA screening for prostate cancer? European Association of Urology 2019. http://uroweb.org/epad19-european-psa-screening-programme-is-on-its-way-part-2/

4. Shieh Y, Eklund M, Sawaya GF, Black WC, Kramer BS, Esserman LJ. Population-based screening for cancer: hope and hype. Nat Rev Clin Oncol 2016; 13(9):550–565.

5. Hugosson J, Godtman RA, Carlson SV, et al. Eighteen-year follow-up of the Göteborg Randomized Population-based Prostate Cancer Screening Trial: effect of sociodemographic variables on participation, prostate cancer incidence and mortality. Scand J Urol 2018 Feb; 52(1):27–37.

6. Blair V, Kahokehr A, Sammour T. Cancer in Māori: lessons from prostate, colorectal and gastric cancer and progress in hereditary stomach cancer in New Zealand. ANZ J Surg 2013; 83(1–2):42–48.

7. Obortova Z, Lawrenson R, Scott N, et al. Treatment modalities for Māori and New Zealand European men with localised prostate cancer. Int J Clin Oncol 2015; 20(4):814–820.

8. Obortova Z, Scott N, Brown C, et al. Survival disparities between Māori and non-Māori men with prostate cancer in New Zealand. BJU Int 2015; 115(Supplement 5), 24–30.

9. Lea RA, Hall D, Chambers GK, Griffiths LR. The New Zealand Maori Population as a Candidate for Admixture Gene Mapping. ASHG Annual Meeting 2006, Abstract 1521.

10. Grummet JP, Weerakoon M, Huang S, Lawrentschuk N, Frydenberg M, Moon DA, O’Reilly M, Murphy D. Sepsis and ‘superbugs’: should we favour the transperineal over the transrectal approach for prostate biopsy?. BJU Int. 2014 Sep; 114(3):384–8.

11. Hübner N, Shariat S, Remzi M, Prostate biopsy: guidelines and evidence. Curr Opin Urol. 2018 Jul; 28(4):354–359.

12. Ahmed H, Ahmed El-Shater Bosaily, Brown L, et al and the PROMIS group. Diagnostic accuracy of multi-parametric MRI and TRUS biopsy in prostate cancer (PROMIS): a paired validating confirmatory study. The Lancet 2017; 389:815–822.

13. Evans SM, Nag N, Order D, Brooks A, Millar JL, Moretti KL, Pryor D, Skala M, McNeil JJ. Development of an International Prostate Cancer Outcomes Registry BJUI Int 2016; 117 Suppl 4:60–67.

14. Pedersen JH, Ashraf H. Implementation and organization of lung cancer screening. Ann Transl Med 2016; 4(8):152.

15. Cornford P, Bellmunt J, Bolla M, et al. EAU-ESTRO-SIOG Guidelines on prostate cancer. Part II: Treatment of relapsing, metastatic and castration-resistant prostate cancer. Eur Urol 2017; 71(4):630–642.

16. Van Poppel H, Bjartell A, Bossi A. EAU White paper on prostate cancer. April 2020 http://uroweb.org/wp-content/uploads/EAU_PCa-WhitePaper-FINAL-VERSION.pdf

Contact diana@nzma.org.nz
for the PDF of this article

View Article PDF

For decades, the optimal management of men with prostate cancer has divided the international urological community. Prostate cancer remains the most expensive cancer in the New Zealand healthcare system, the most commonly diagnosed with around 4,000 new cases per year, and a common cause of death. Ultimately, the vast variability in clinical expression and progression of prostate cancer as a disease, combined with the potential morbidity associated with treatment, has proven to be a conundrum to which the unequivocal truth is yet to be uncovered.

The morale among clinicians and scientists was high when the prostate specific antigen (PSA) blood test was discovered in 1979 and urologists worldwide started using it as a “test for prostate cancer”. However, PSA turned out not to be the panacea that we were expecting for screening and diagnosing prostate cancer. Features of a so-called ideal screening test are often cited:

• The diagnostic/screening test should have a high sensitivity and specificity.

• The disease being screened for should have a high prevalence and significant morbidity and/or mortality and also have a long latent (pre-clinical) phase.

• Treatment for the disease should be available and curative, or significantly palliative. Side-effects of diagnosis and treatment should be minimal.

• Cost-benefit ratio of screening and treatment should be favorable, ie, minimal cost, maximal benefit, therefore high value.

In the topical article authored by Matti and Zargar-Shoshtari,1 the authors clearly state the evidence around prostate cancer screening has shifted. We in New Zealand need to rethink our advice in this area. A national prostate cancer screening programme would require considerable resources, standard simple advice and access to diagnostic investigations.

Population-based screening is where a screening test is offered systematically to all individuals in a defined target group within a framework of agreed policy, protocols, quality management, monitoring and evaluated through a quality improvement framework.2 While the European Association of Urology (EAU) is currently driving the planned implementation of coordinated prostate cancer screening programmes in European countries,3 establishing such a programme in other countries including New Zealand, will require the development of individualised models based on local health systems, improved resources and infrastructure in contemporary diagnostics and treatments.

Pensive planning will be required to construct the optimal prostate cancer screening cascade so that we do not miss the mark, as the line between benefit and harm to our patients is indeed a thin one. The first area of refinement is determining who the population is to be screened by using risk stratification; in the case of prostate cancer this is based primarily on age and family history and ethnicity. There is good international evidence that such a systematic screening for prostate cancer may reduce sociodemographic health inequity.4,5 This is a lucrative prospect to us as urologists in New Zealand, where we are still trying to map out the exact interplay of factors that contribute to Māori men having a higher prostate cancer mortality but a lower diagnosis rate.6

In fact, Māori men have the highest mortality rate from prostate cancer among all indigenous New Zealand populations. In an attempt to explain this, various factors have been studied; these include among others socioeconomic disparities, demographics, access to healthcare, diet, body mass index and differences in treatment modalities.7,8 Regrettably, current research findings still leave us with a significant and unexplained gap in outcomes and survival in Māori men with prostate cancer when compared to their fellow New Zealanders of European descent. When designing a nationwide, population-based screening programme for prostate cancer it would be imperative to ensure that not only the known inequities are factored into the screening cascade, but also that the as yet unexplored causative factors in this population group—one of which being genetic risk factors—are adequately investigated through prudently designed genetic research studies.9

If the threshold for prostate cancer screening is met, the next step of the screening cascade is the digital rectal exam (DRE) and PSA test, the optimal frequency of which is to be determined. Currently DRE and PSA testing in asymptomatic men in New Zealand is sporadic, dependent on the patient or GP instigating this investigation. Māori men may have a cultural barrier to such a pathway due to the low tolerance of a DRE. Based on this current New Zealand case finding scenario, there is an unequal testing regimen in our population. A well supported, standardised screening programme with a clear message to patients and GPs, plus accurately collected data, would improve the prostate cancer diagnosis to all men, including those men not currently tested.

A prostate biopsy is required for a diagnosis of prostate cancer. Outpatient local anaesthetic trans rectal biopsy is a standard of care. Trans-perineal prostate biopsy under general local anaesthetic is increasingly being undertaken due to improved diagnostic accuracy and reduced sepsis.10,11

In recent years an additional aid to the diagnosis of prostate cancer is multi-parametric Magnetic Resonance Imaging (mpMRI).12 MRI scanning is not consistently available in New Zealand due to cost and availability. MRI can create images that show the relative presence of prostate cancer, using a PI-RADS scale 1–5 (Prostate Imaging, Reporting and Data System). Pi-RADS 1–3 low risk 10–20% likelihood cancer, PI-RADS 4,5 60–90% risk, and allowing a targeted biopsy. A standard of care in the NHS is an MRI prior to consideration of a prostate biopsy, yet this investigation is only undertaken in a small number of men before biopsy in New Zealand. Up to 40% of men may delay or avoid a prostate biopsy with a negative MRI.12The ultimate aim of clinical workup which will follow a positive test is to determine the aggressiveness and extent of disease. In New Zealand approximately 40% of men have low risk of disease, the majority undergoing active surveillance to lower the risk of treatment-related morbidity. Surgical treatment is the commonest treatment in intermediate and high-risk localised disease, with the majority as an open retropubic procedure. Internationally, robotic prostatectomy is the standard of care with over 60% of men in Australia and over 80% of men treated this way in the NHS. Robotic prostate surgery is not available in the public system in New Zealand.

While we as clinicians often find it challenging to navigate the ever-changing landscape of this disease with many aspects still uncharted, we should not lose sight of the thousands of men who are cured of prostate cancer every year through early detection, efficient multidisciplinary decision-making and appropriate locally delivered treatment.

Comprehensive cancer registries play an important role in determining the value of cancer treatment . The New Zealand National Prostate Cancer Outcomes Registry, funded by a Movember grant, is helping to understand and improve the outcomes of men diagnosed with prostate cancer. Prostate Cancer Outcomes Australia and New Zealand (PCORANZ) was instigated in 2016 and is currently collecting demographic, diagnostic, treatment and patient outcomes.13 Over 90% of New Zealand public hospital patient data is collected and now being reported back to clinicians and hospitals in standard six-monthly reports. These reports drive quality improvement and may highlight variance in care.

While frameworks exist to deal with the general design and implementation of national screening programmes,14 addressing the elephant in the room of who will foot the bill in New Zealand for this grand plan is a more challenging task. Apart from the cost of increased volumes of PSA-tests, the subsequent impact on resources, including human resources, will need to be factored in. However, in monetary terms it is simply a matter of investing in modestly increased costs at the early stages of the cancer journey in order to avoid the eye-watering (alternative budget-crippling) costs often associated with the treatment of the advanced stages of prostate cancer. PSA tests are relatively inexpensive even if they need to be repeated numerous times in a patient’s lifetime. Even if combined with the costs of a multi-parametric MRI scan it is still considerably cheaper than the treatment of advanced and metastatic disease, the latter of which only marginally improves survival.15 While the costs of robot-assisted radical prostatectomy rarely exceed US$17,000 per patient, the costs for the management of patients with metastatic, castration-resistant prostate cancer can be up to US$350,000 during a patient’s lifetime.16 In addition to the cost saving associated with early detection of prostate cancer, the surgical outcomes and post-treatment quality of life and length of life of our patients are superior when their tumours are treated in the earlier stages of the disease.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Amir Zarrabi, TD Scott Chair in Urology, University of Otago, Dunedin; Stephen Mark, Consultant Urologist, Christchurch Hospital, Christchurch.

Acknowledgements

Correspondence

Stephen Mark, Consultant Urologist, Christchurch Hospital, Christchurch.

Correspondence Email

stephen@urology.co.nz

Competing Interests

Nil.

1. Matti B, Zargar-Shoshtari K. Prostate cancer screening in New Zealand: lessons from the past to shape the future in the light of changing evidence. N Z Med J 2020; 133(1523):87–95.

2. Australian Government Department of Health Standing Committee on Screening. Population based screening framework 2018. http://www.health.gov.au/resources/publications/population-based-screening-framework

3. Van Poppel H, Chapple C, Montorsi F, et al. Policy paper on PSA screening for prostate cancer: Has the time come to reconsider structured population-based PSA screening for prostate cancer? European Association of Urology 2019. http://uroweb.org/epad19-european-psa-screening-programme-is-on-its-way-part-2/

4. Shieh Y, Eklund M, Sawaya GF, Black WC, Kramer BS, Esserman LJ. Population-based screening for cancer: hope and hype. Nat Rev Clin Oncol 2016; 13(9):550–565.

5. Hugosson J, Godtman RA, Carlson SV, et al. Eighteen-year follow-up of the Göteborg Randomized Population-based Prostate Cancer Screening Trial: effect of sociodemographic variables on participation, prostate cancer incidence and mortality. Scand J Urol 2018 Feb; 52(1):27–37.

6. Blair V, Kahokehr A, Sammour T. Cancer in Māori: lessons from prostate, colorectal and gastric cancer and progress in hereditary stomach cancer in New Zealand. ANZ J Surg 2013; 83(1–2):42–48.

7. Obortova Z, Lawrenson R, Scott N, et al. Treatment modalities for Māori and New Zealand European men with localised prostate cancer. Int J Clin Oncol 2015; 20(4):814–820.

8. Obortova Z, Scott N, Brown C, et al. Survival disparities between Māori and non-Māori men with prostate cancer in New Zealand. BJU Int 2015; 115(Supplement 5), 24–30.

9. Lea RA, Hall D, Chambers GK, Griffiths LR. The New Zealand Maori Population as a Candidate for Admixture Gene Mapping. ASHG Annual Meeting 2006, Abstract 1521.

10. Grummet JP, Weerakoon M, Huang S, Lawrentschuk N, Frydenberg M, Moon DA, O’Reilly M, Murphy D. Sepsis and ‘superbugs’: should we favour the transperineal over the transrectal approach for prostate biopsy?. BJU Int. 2014 Sep; 114(3):384–8.

11. Hübner N, Shariat S, Remzi M, Prostate biopsy: guidelines and evidence. Curr Opin Urol. 2018 Jul; 28(4):354–359.

12. Ahmed H, Ahmed El-Shater Bosaily, Brown L, et al and the PROMIS group. Diagnostic accuracy of multi-parametric MRI and TRUS biopsy in prostate cancer (PROMIS): a paired validating confirmatory study. The Lancet 2017; 389:815–822.

13. Evans SM, Nag N, Order D, Brooks A, Millar JL, Moretti KL, Pryor D, Skala M, McNeil JJ. Development of an International Prostate Cancer Outcomes Registry BJUI Int 2016; 117 Suppl 4:60–67.

14. Pedersen JH, Ashraf H. Implementation and organization of lung cancer screening. Ann Transl Med 2016; 4(8):152.

15. Cornford P, Bellmunt J, Bolla M, et al. EAU-ESTRO-SIOG Guidelines on prostate cancer. Part II: Treatment of relapsing, metastatic and castration-resistant prostate cancer. Eur Urol 2017; 71(4):630–642.

16. Van Poppel H, Bjartell A, Bossi A. EAU White paper on prostate cancer. April 2020 http://uroweb.org/wp-content/uploads/EAU_PCa-WhitePaper-FINAL-VERSION.pdf

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