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The Melbourne Consensus Statement on Prostate Cancer Testing




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The final, peer-reviewed version of this Consensus Statement has now been published in BJUI. You can find it here. The full citation is Murphy, D. G., Ahlering, T., Catalona, et al. (2014), The Melbourne Consensus Statement on the early detection of prostate cancer. BJU International, 113: 186–188. doi: 10.1111/bju.12556

A consensus view on the early detection of prostate cancer, led by experts at the Prostate Cancer World Congress, Melbourne, 7–10th August 2013

Recent guideline statements and recommendations have led to further confusion and controversy regarding the use of Prostate Specific Antigen (PSA) testing for the early detection of prostate cancer. Despite high-level evidence for the use of PSA testing as a screening tool, and also for its role as a predictor of future risk, the U.S. Preventive Services Taskforce (USPSTF) has called for PSA testing to be abandoned completely [1], and many men are therefore not given the opportunity for shared decision-making. Other groups such as the American Urological Association, National Comprehensive Cancer Network, and European Association of Urology support a role for PSA screening but with somewhat conflicting recommendations. The majority of guideline statements have endorsed the role of shared decision-making for men considering PSA testing.

To address these somewhat conflicting and confusing positions, a group of leading prostate cancer experts from around the world have come together at the 2013 Prostate Cancer World Congress in Melbourne and have generated the following set of consensus statements regarding the use of PSA testing. The goal of these statements is to bring some clarity to the confusion that exists with existing guidelines, and to present reasonable and rational guidance for the early detection of prostate cancer today.

1.        Consensus Statement 1: For men aged 50–69, level 1 evidence demonstrates that PSA testing reduces prostate cancer-specific mortality and the incidence of metastatic prostate cancer. In the European Randomized Study of Screening for Prostate Cancer (ERSPC), screening reduced metastatic disease and prostate cancer-specific mortality by up to 30% and 21% respectively in the intent-to-treat analysis, with a greater reduction after adjustment for noncompliance and contamination[2,3]. In addition, the Goteborg randomized population-based randomized trial showed a reduction in metastatic disease and prostate cancer mortality with screening starting at age 50 [4]. The degree of over-diagnosis and over-treatment reduces considerably with longer follow-up, such that the numbers needed to screen and numbers needed to diagnose compare very favourably with screening for breast cancer. While routine population-based screening is not recommended, healthy, well-informed men in this age group should be fully counseled about the positive and negative aspects of PSA testing to reduce their risk of metastases and death. This should be part of a shared decision-making process.

 2.        Consensus Statement 2: Prostate cancer diagnosis must be uncoupled from prostate cancer intervention. Although screening is essential to diagnose high-risk cases within the window of curability, it is clear that many men with low-risk prostate cancer do not need aggressive treatment. Active surveillance protocols have been developed and have been shown to be a reasonable and safe option for many men with low-volume, low-risk prostate cancer [5,6]. While it is accepted that active surveillance does not address the issue of over-diagnosis, it does provide a vehicle to avoid excessive intervention. Active surveillance strategies need standardization and validation internationally to reassure patients and clinicians that this is a safe strategy.

 3.        Consensus Statement 3: PSA testing should not be considered on its own, but rather as part of a multivariable approach to early prostate cancer detection. PSA is a weak predictor of current risk and additional variables such as digital rectal examination, prostate volume, family history, ethnicity, risk prediction models, and new tools such as the phi test, can help to better risk stratify men. Prostate cancer risk calculators such as those generated from the ERSPC ROTTERDAM (www.prostatecancer-riskcalculator.com), the Prostate Cancer Prevention Trial (PCPT) (https://deb.uthscsa.edu/URORiskCalc/Pages/uroriskcalc.jsp), and from Canada (prostaterisk.ca), are useful tools to help men understand the risk of prostate cancer in these populations. Further developments in the area of biomarkers, as well as improvements in imaging will continue to improve risk stratification, with potential for reduction in over-diagnosis and over-treatment of lower risk disease.

4.        Consensus Statement 4: Baseline PSA testing for men in their 40s is useful for predicting the future risk of prostate cancer. Although these men were not included in the two main randomized trials, there is strong evidence that this is a group of men who may benefit from the use of PSA testing as a baseline to aid risk stratification for their likely future risk for developing prostate cancer [7], including clinically significant prostate cancer. Studies have shown the value of PSA testing in this cohort for predicting the increased likelihood of developing prostate cancer 25 years later for men whose baseline PSA is in the highest centiles above the median [8,9]. For example, those men with a PSA below the median could be spared regular PSA testing as their future risk of developing prostate cancer is comparatively low, whereas those with a PSA above the median are at considerably higher risk and need closer surveillance. The median PSA for men aged 40–49 ranges from 0.5–0.7 ng/ml, with the 75th percentile ranging from 0.7–0.9ng/ml. The higher above the median, the greater the risk of later developing life-threatening disease. We recommend that a baseline PSA in the 40s has value for risk stratification and this option should be discussed with men in this age group as part of a shared decision-making process.

 5.        Consensus Statement 5: Older men in good health with over ten year life expectancy should not be denied PSA testing on the basis of their age. Men should be assessed on an individual basis rather than applying an arbitrary chronological age beyond which testing should not occur. As life expectancy improves in many countries around the world (men aged 70 in Australia have a 15 year life expectancy), a small proportion of older men may benefit from an early diagnosis of more aggressive forms of localised prostate cancer, just as it is clear that men with many competing co-morbidities and less aggressive forms of prostate cancer are unlikely to benefit irrespective of age. Likewise, a man in his 70s who has had a stable PSA at or below the median for a number of years previously is at low risk of developing a threatening prostate cancer and regular PSA screening should be discouraged.

An important goal when considering early detection of prostate cancer today, is to maintain the gains that have been made in survival over the past thirty years since the introduction of PSA testing, while minimizing the harms associated with over-diagnosis and over-treatment. This is already happening in Australia where over 40% of patients with low-risk prostate cancer are managed with surveillance or watchful waiting [10], and in Sweden where 59% of very low risk patients are on active surveillance. This is also reflected in current guidelines from the EAU, NCCN and other expert bodies, and in a comment from AUA Guideline author Dr Bal Carter in the BJU International.

Abandonment of PSA testing as recommended by the USPSTF, would lead to a large increase in men presenting with advanced prostate cancer and a reversal of the gains made in prostate cancer mortality over the past three decades.

However, any discussion about surveillance is predicated on having a diagnosis of early prostate cancer in the first instance. As Dr Joseph Smith editorialized in the Journal of Urology following the publication of the ERSPC and PLCO trials, “treatment or non-treatment decisions can be made once a cancer is found, but not knowing about it in the first place surely burns bridges” [11]. A key strategy therefore is to continue to offer well-informed men the opportunity to be diagnosed early, while minimizing harms by avoiding intervention in those men at low risk of disease progression. This consensus statement provides some guidance to help achieve these goals.

 
Signatories:

A/Professor Declan G Murphy, University of Melbourne, Peter MacCallum Cancer Centre, Melbourne, Australia

Professor Tony Costello, University of Melbourne, Royal Melbourne Hospital, Melbourne, Australia

Dr Patrick C Walsh, The James Buchanan Brady Urological Institute, Johns Hopkins University, USA

Dr Thomas Ahlering, University of California, Irvine, School of Medicine, USA

Dr William C Catalona, Northwestern University Feinberg School of Medicine, USA

Dr Oliver Sartor, Tulane University School of Medicine, USA

Dr Tom Pickles, British Columbia Cancer Agency, Canada

Dr Jane Crowe, Australian Prostate Cancer Research Centre, Australia

Dr Addie Wootten, Royal Melbourne Hospital, Australia

Ms Helen Crowe, Royal Melbourne Hospital, Australia

Professor Noel Clarke, Manchester University, The Christie Hospital, Manchester, UK

Dr Matthew Cooperberg, University of California San Francisco, Helen Diller Family Comprehensive Cancer Centre, USA

Dr David Gillatt, University of Bristol, Bristol Urological Institute, Bristol, UK

Dr Martin Gleave, University of British Columbia, The Vancouver Prostate Centre, Vancouver, Canada

Dr Stacy Loeb, New York University, USA

Dr Monique Roobol, Erasmus University Medical Centre, Rotterdam, The Netherlands

Footnote:

The median PSA for men aged 40–49 ranges from 0.5–0.7ng/ml. The 75th percentile ranges from 0.7–0.9ng/ml.

This blog was originally published on 7th August 2013 and was updated on 13th August 2013.

References:

[1] Moyer VA, Force USPST. Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157:120–34.

[2] Schroder FH, Hugosson J, Roobol MJ, Tammela TL, Ciatto S, Nelen V, et al. Prostate-cancer mortality at 11 years of follow-up. N Engl J Med. 2012;366:981–90.

[3] Schroder FH, Hugosson J, Carlsson S, Tammela T, Maattanen L, Auvinen A, et al. Screening for prostate cancer decreases the risk of developing metastatic disease: findings from the European Randomized Study of Screening for Prostate Cancer (ERSPC). Eur Urol. 2012;62:745–52.

[4] Hugosson J, Carlsson S, Aus G, Bergdahl S, Khatami A, Lodding P, et al. Mortality results from the Goteborg randomised population-based prostate-cancer screening trial. Lancet Oncol. 2010;11:725–32.

[5] Bul M, Zhu X, Valdagni R, Pickles T, Kakehi Y, Rannikko A, et al. Active surveillance for low-risk prostate cancer worldwide: the PRIAS study. Eur Urol. 2013;63:597–603.

[6] Bangma CH, Bul M, van der Kwast TH, Pickles T, Korfage IJ, Hoeks CM, et al. Active surveillance for low-risk prostate cancer. Crit Rev Oncol Hematol. 2012.

[7] Loeb S. Use of baseline prostate-specific antigen measurements to personalize prostate cancer screening. Eur Urol. 2012;61:875–6.

[8] Vickers AJ, Ulmert D, Sjoberg DD, Bennette CJ, Bjork T, Gerdtsson A, et al. Strategy for detection of prostate cancer based on relation between prostate specific antigen at age 40-55 and long term risk of metastasis: case-control study. BMJ. 2013;346:f2023.

[9] Lilja H, Cronin AM, Dahlin A, Manjer J, Nilsson PM, Eastham JA, et al. Prediction of significant prostate cancer diagnosed 20 to 30 years later with a single measure of prostate-specific antigen at or before age 50. Cancer. 2011;117:1210–9.

[10] Evans SM, Millar JL, Davis ID, Murphy DG, Bolton DM, Giles GG, et al. Patterns of care for men diagnosed with prostate cancer in Victoria from 2008 to 2011. Med J Aust. 2013;198:540–5.

[11] Smith JA, Jr. What would you do, doctor? J Urol. 2009;182:421–2.

  1. Paul Anderson
    Finally a position on PSA testing that combines common sense with evidence. Good work!
  2. Mike Leveridge
    Serious congratulations to the crack team who conceived and created this excellent document. It should be required reading for all players: urologists, primary care physicians and "e-patients" (anyone engaged and informed about the choices they face as they consider prostate cancer screening). A few comments in no particular order (apologies if I wander):

    1. As Rajiv (twitter.com/DrRKSingal) has noted already, statement #2 is critical - the uncoupling of a prostate cancer diagnosis from treatment. In the age of active surveillance and acknowledgment of the natural history of low-risk disease, this cannot be overstated or repeated often enough, and is the linchpin of the misguided notion espoused most notably by the USPTF and others who cling to the outdated and misnamed 2009 ERSPC "NNT" of 49. (see statement #1 for other reasons that this is misguided)

    2. Statement #3 is also critical as it establishes an acceptance of PSA's shortcomings. Those who espouse the end of PSA screening often pit themselves against the straw man of the PSA-is-all zealot. This softened stance demolishes this false dichotomy and makes the anti-PSA absolutist stance more starkly unreasonable.

    3. The social media aspect here once again cannot be ignored. This guideline was released here on the BJUI Blogs immediately upon its public presentation in Melbourne. This is a strong endorsement of the ability of SoMe to stand in parallel to conventional media and constrained academic publication as a real mode of information distribution. Needless to say to most who will read this, Twitter has been crackling with links and retweets of these data (dozens in my feed alone), and the impression statistics must be enormous. Much credit to Declan and the BJUI SoMe crew for their first-domino work here.

    4. The conventional media aspect is also impressive to me. The PCWC seems robustly covered by Australian media, a testament to the organizers. This story seems to have made headlines across Australia. Other Urological societies could stand to take note, especially given the force of public opinion in matters as critical as cancer screening. We have doubtless all had patients developing cynical approaches to PSA testing based on what they have seem and read recently, and it is nice to see this side of the debate register some air time (one caveat might be the promulgation of sensational headlines: The Australian: "Prostate experts end PSA test confusion"; I think Bloomberg's "Prostate Test Warrants Rational Use" is much more becoming of the discipline, but I suppose we can indulge some rabble-rousing if it draws attention to the message).

    5. One thing that I've been thinking more about here is branding - not sure if I have a thesis here or even a formed opinion, but the repetition of the whole name "Melbourne Consensus Statement" is clearly intentional, and the conference was renamed the Prostate Cancer World Congress with some fanfare after the great success (and my first significant "attendance" at a meeting through Twitter) from the Australian Prostate Cancer Conference. I keep thinking of things like "the Phoenix definition" etc. Anyway, kudos to the efforts of the usual suspects for adding a meta-layer to their work to sear in the message.

    Congratulations again for a fine, balanced and evidence-based consensus.

    Mike
  3. Richard Hockey
    "Abandonment of PSA testing as recommended by the USPSTF, would lead to a large increase in men presenting with advanced prostate cancer and a reversal of the gains made in prostate cancer mortality over the past three decades. "
    Where is the evidence for this? This sort of throwaway statement has no place in the guidelines.
  4. Dr Rajiv Singal
    I will comment first. I wrote this blog in BJUI: (https://www.bjuinternational.com/bjui-blog/early-prostate-cancer-detection-one-canadian-urologists-perspective/) in June essentially in response to what I felt was a real step backwards in terms of guideline development for prostate cancer detection. As urologists we have significantly over-treated this disease and now run the risk of having the decision-making taken away from us. The issue is not that screening is harmful but that biopsy can be and certainly the treatment cascade is. A major step forward is Statement #2. This notion of uncoupling diagnosis from treatment is obvious but will take honest work and a lot of time to talk to patients about. 'Cancer' is a loaded word and we need to be the stewards of thoughtful clinical recommendations. Well done guys. In the current digital world these guidelines should be embraced worldwide and the rest of us should strive to further improve them.
  5. Associate Professor Ian Haines
    This appears to be a pointless, self-serving, unbalanced, unhelpful piece of 'propoganda' by a self-selected group of like-minded urologists with huge financial conflicts of interest. It seems no more useful than a group of 10 pig-farmers telling us that we should eat more bacon. The harms caused by alarming 50% of men with PSAs above the median that a tiny number may die at a median age of 81 from a disease for which there is no proven effective treatment in the PSA era is absurd. Then to advocate screening of some men over 70 years old for which there is not a shred of evidence defies comprehension. Where are the radiation oncologists, the medical oncologists, the psychologists, the nurse specialists and the epidemiologists on this 'consensus panel'? The NHMRC and US preventive Health Task force have issued carefully considered and dispassionate recommendations free of conflicts of interest and they do contribute positively to the debate.
    • Eric Starra
      What do you define as effective treatment??
    • Henry Woo
      The authors are to be congratulated on this excellent appraisal of the latest and best evidence to assist men and their doctors in reaching a decision as to whether they wish to undergo PSA testing or not. This piece represents a consensus statement of prostate cancer experts and never pretends to be a set of guidelines where the process of extensive multidisciplinary consultant forms part of the process.

      This consensus statement makes 5 statements, none of which are recommendations for screening. Each one of these statements considers the individual circumstances of a man rather than populations of men. Each statement provides information that allows each man to put the information into their own context. It is morally wrong to deny individuals factual information that could influence their personal decisions about their own health.

      The head in the sand approach that is still advocated by those who preach against prostate cancer testing of any sort would foster a return to the bad old days when presentation to emergency departments with devastating symptoms due to late disease were common place. It also seems highly likely we would also see a return to the trend of increasing prostate cancer mortality as evidenced in cancer council data.

      These consensus statements are also consistent with the movement towards middle ground in the prostate cancer screening debate. We realise that over-diagnosis and over-treatment have occurred in our genuine desire to help our patients. I feel fortunate to never have observed clinicians act in a manner where their primary objective was other than first and foremost in the interests of their patients. However in doing so, we have all been guilty of over-diagnosis and over-treatment of a number of our patients and we are now learning from this. We are getting smarter about who we should biopsy and who we should treat. We are also getting smarter about how we can treat the side effects of cancer treatment. Whilst we may not have perfect solutions, more efforts than ever before are being put into such endeavours. To me, that represents genuine commitment by the profession to change our approach to prostate cancer testing and treatment.

      It does disturb me that those who vocally oppose any form of prostate cancer testing, refuse to shift from the extremes of their position and consider moving towards a middle ground approach that factors in the problem of prostate cancer related morbidity and mortality. Data supports that this move should be made. I think we will end up meeting halfway from what was historically poles apart on the matter but it takes two to tango.
    • Manuel Rosenbaum
      As a former biomedical researcher and prostate cancer survivor, I take serious issue with this statement. You refer to this as "a disease for which there is no proven effective treatment." Then please explain why the mortality rate has declined with the implementation of PSA testing. Also why newly diagnosed cases are now more often in the early, more treatable stages.

      You also reject screening of men over 70 years old. That is also absurd in the is age of greater longevity. I was diagnosed with a Gleason 9 cancer at age 74 + 7 months in 2004, that is TEN YEARS ago. Without diagnosis by PSA and effective radiation (IMRT) treatment, I would be long dead by now.
  6. Benjamin Davies
    Dear Adjunct Clinical Associate Prof from Monash University,

    I love bacon and I do not need a pig farmer to advocate that position. Similarly, I hate prostate cancer (as you should) and I do need an oncologist to tell me otherwise.

    In real academia (something you appear to be marginally affiliated with) we disparage each other not with farm animals but with data. So where is the data that we are financially motivated? Is the good Dr. Cooperberg driving to work in a Bentley from his Bay Area Estate? No. Is Dr. Loeb dripping with diamonds as she explains her work? The consensus panel is made up of real professors who are largely uncoupled from financial incentive in the form of - wait for it - salaries. And even if they were motivated by money how does that change epidemiologic data? Can we change the Goteburg data because we are rich fancy urologists? https://www.ncbi.nlm.nih.gov/pubmed/20598634

    "from a disease for which there is no proven effective treatment in the PSA era is absurd" Yes sir. I see you are opposed to Level 1 evidence from randomized controlled trials. https://www.ncbi.nlm.nih.gov/pubmed/21542742

    But enough with real data! Let us add Nurse Specialists to the discussion because they have so much to tell us OR better yet let us add psychologists since they are exquisitely trained in cancer screening studies.

    Associate Prof
    Ben Davies
    • Ian Haines
      Thank you Benjamin.
      Firstly Goteberg was essentially a subset of the ERSPC, which was a compilation of 7 separate studies, 5 of which showed no prostate cancer-specific mortality reduction for screening. And Goteborg,as part of the very positive Swedish study, was largely reported twice. More importantly , and unlike PLCO, the ERSPC and Goteborg had a huge disparity between screened and control groups for use of hormone therapy alone as primary treatment....a treatment that is proven to be inferior to RT plus endocrine therapy and is generally regarded as an inappropriate and inadequate treatment. Whilst this may be due to stage migration, there may be other factors at play and this treatment imbalance may explain the different outcomes. The PLCO consented patients and then randomised them so that all patients were treated in a similar way in similar centres....whereas the European studies essentially randomised patients and then consented only the screened patients so that control patients were largely unaware that they were in a study and were 'treated' in regional centres and screened patients in major treatment centres. Until the breakdown of stage/risk, primary treatment given and prostate cancer deaths is provided for these 2 studies the jury is still out on whether the results of these 2 studies are credible.
      Secondly, the Bill-Axelson and Holmberg study was of symptomatic men with T1-2 disease only in the pre-PSA era and is not really applicable at all to the current situation...only a small percentage were diagnosed by PSA.
      Thirdly, it sounds rather superior and just a little arrogant to disparage nurse specialists who do legitimate research on the complications of surgery and the huge social, personal and financial costs of treating the impotence, incontinence, depression and relationship breakdown associated with the vast over diagnosis and over treatment of this disorder...largely free of financial conflicts of interest.
      Respect for one's research colleagues is a two-edged sword Benjamin....we all do well to listen carefully and respectfully, speak honestly, openly and without fear or favour and acknowledge the huge impact of conflict of interest...achieving the best possible outcomes for men must remain our focus.
      • Mark Frydenberg
        Quoting PLCO as the shining example of a RCT, ignores the basic fact that this study simply compares a 85% screened group to a 52% unscreened group. At best one could only conclude that mass population screening may not confer a benefit over opportunistic testing at 10 years but one cannot conclude from the study design that PSA testing should be abolished . From ERSPC and Goteborg (which has not been included twice as many of the patients were younger than the ERSPC age limits) one can conclude that whilst the absolute risk of dying from prostate cancer if one chooses not to screen is low, if men are interested in reducing that risk, it is proven that testing does achieve that goal. The US Task Force recommendations have caused much controversy and in Australia there is a process underway for a multidisciplinary statement which includes all the groups that are mentioned in the posts above.

        In an era of collaborative care of cancer patients, there is no evidence that anyone is debating this important issue with conflicts of interest at heart. Indeed we have been striving to reduce the need for biopsies and invasive treatments over the last few years, measures that do not support views about financial interests in this discussion.
        We are striving to work with our medical oncology, primary care, radiology and nursing colleagues to achieve the best possible outcomes for men suffering with prostate cancer. We welcome debate and are happy to consider and respect alternative points of view. Ultimately the people we serve will educate themselves and make up their own minds.
    • Ian Haines
      And another thing Benjamin....I have been involved as a full-time medical oncologist for over 30 years providing hands-on one-to-one care for many thousands patients from diagnosis till cure or death. I do not think that any oncologist anywhere has personally provided day-to-day care for more patients than me. I regard my clinical experience and clinical knowledge plus my age (58) and male sex as giving me the qualifications necessary to contribute to this important debate....the overdiagnosis and overtreatment of this disease is placing a huge, unnecessary and unsustainable burden on western health budgets...I will continue to try and do my bit to improve this serious and worsening situation.
  7. Syd Weinstein
    I think that this Concesus Statement is the most sensible, practical and well thought out document available to clinicians who have the responsibility of treating and advising patients and their families that I have seen.
    Congratulations to the panel.
    I agree with Mike Leveridge that this should be essential reading for all who are interested in prostate cancer and its management
  8. Dr Albert Akkad
    I agree with all the statment but we need to establish what step has to be taken in active surveillance
    1 Biopsies
    2 MRI S
    3 focal treatment?electroporation?
    4 Psa
    5 Pca3
    6 Phi
    7 Prolaris

    There must be a statement on that
  9. Dr Jason Y Lee
    Dear authors of the Melbourne Consensus Statement,

    Firstly, I'd like to congratulate you on a truly thoughtful & honest take on the veritable PSA fecal-storm that has resulted after the USPSTF guidelines were released. The consensus statement provides clear and concise, evidence-based guidelines for not only the practicing uro-oncologist, but the front-line primary care physician searching for answers in the muddy waters.

    Clearly, we have done a disservice to many fathers, brothers, and sons with over-treatment of clinically insignificant disease. With the educated and timely implementation of active surveillance (more data still forthcoming) and the proper utilization of PSA screening as recommended in this document, we can continue to improve the quality of care delivered to our prostate cancer patients.

    "When cure is necessary, is it possible; and when possible, is it necessary" - W. Whitmore
  10. Nick Brook
    Reading the comments above, its clear that the gloves have come off!

    My take:

    The word ‘consensus’ is used, although really this was a group of talented, respected, bright, like-minded individuals who probably had the same opinions on PSA testing (I note ‘screening’ is dropped) before they sat down. Less a consensus (an acceptable resolution) and more an agreement between people who already agree. You will find that defending your position would have been easier if you had other professional groups involved, and some who are PSA-doubters. I do agree with Ben that Nurse Practitioners and Psychologists have little to add to what is essentially a statistical/epidemiological debate, but others (med/rad onc, ANZ public health, GPs) should have been involved to avoid the accusation that this was a self-serving exercise. Essentially, the composition of the panel is the polar opposite of the USPSTF, and you could have learned from their mistake in this respect.

    Whilst anyone in his or her right mind must agree that the evidence shows PSA testing reduces CaP-related death, there is not a mention of the word ‘harm’ in the consensus...absolutely central to the entire debate. We could stop all road-related deaths tomorrow if we banned driving, but how many people would come to ‘harm’ as a result of not being able to use an ambulance? I believe the data, and I believe this consensus, but to defend it, you must at least tip your hats to this issue. Also, don’t confuse ‘harm’ with ‘ham’…see the Ben Davies/Ian Haines love-in, above.

    The consensus has been sold as an easy to use document for GPs (who are the ones in the front line of the discussion). Again, whilst I applaud your efforts and believe the consensus is a big step in the right direction, it really isn’t that helpful for GPs. What will they make of prostate size? Or ‘multivariable approach’? Or the current muddle about testing in the 40s (again, I am a believer in this, but we are far from a consensus on this difficult topic and its implications). Or the ‘uncoupling’? There is confusion where there should be simplicity.

    Last, the links to the web risk assessment calculators are US/European based, and under ‘ethnicity’ we can choose white/black/Asian/other. This means that Aboriginal people will be grouped under an ‘other’ which is likely irrelevant to their risk. As an ANZ consensus, this needs to be addressed.

    On a more positive note…bloody well done to all for tackling a very difficult task, which should be seen as an dynamic and evolving document. 9/10.
  11. Jon Rees
    As a GP it is quite clear to me that men are simply not going to accept the USPSTF advice to put PSA back in it's box and take a nihilistic attitude to prostate cancer detection. However, our current position, in the UK at least, of ad hoc testing for those who ask for it is clearly unsatisfactory. We need to work out firstly who to test, how often, who to biopsy (and how) before we worry about the whole issue of overtreatment.
    This statement provides clarity to me in a way that many more lengthy guidelines have failed to do. In particular, the recommendations around baseline PSA for risk stratification, and the use of risk calculators rather than isolated PSA results are particularly pertinent to those of us in primary care. Just because our current approach is not working well does not mean we should abandon the fight against this disease and used correctly, PSA is clearly a vita part of this process.
  12. David Bouchier-Hayes
    This consensus statement addresses some major concerns that have existed in the community of surgeons treating prostate cancer in an up front manner, at the stage when prostate cancer is organ confined. This patient population differs considerably from patients presenting with metastatic disease, inevitably leading to hormone refractory prostate cancer, which is the challenging population faced by medical oncologists.
    As a 'non-academic urologist', I am delighted that this consensus statement clarifies many of the issues confounding not only urologists, but also patients and primary care physicians in relation to the issue of prostate cancer/PSA screening. Moving the direction from having an elevated PSA leading automatically to biopsy and then treatment for all with cancer, to engaging the patient in a discussion concerning a need for PSA testing, and then individualising treatment to the patient with respect to age, possible lethality of cancer etc (ie uncoupling diagnosis from treatment) is an important, and poorly understood (especially by the general public) aspect in the management of elevated PSA and/or prostate cancer.
    This consensus statement defines this uncoupling extremely well, amongst other excellent contributions. Continued disparaging of PSA testing will inevitably send the message that no-one should have a PSA done at all (as is being pushed now), and then we are back to castrating men, dealing with spinal collapse, paraplegia etc with a marked increase in morbidity and mortality from prostate cancer, and have stepped backwards 30 years. This group of patients will then definitely need our medical oncology colleagues input, but at present, lifespan increases with systemic, anti neoplastic treatments are offering increased lifespan of mere months, not the years and decades of survival (or very often total cure) offered by surgery.
  13. Alexander Kutikov
    Given the varying views within this thread, it important to contextualize these guidelines for the casual visitor of this page. The Melbourne Consensus Statement on Prostate Cancer Testing is a superb effort by a group of thought-leaders -- whose legitimacy in the space of prostate cancer is beyond reproach -- to articulate and publicize their expert opinion on this critical topic. Regardless whether one agrees or disagrees with the nuances of the statement, it is hard to find individuals with more integrity than the members of this panel.
  14. Casey Ng
    We can't over emphasis the importance of Consensus Statement #2. We need to separate diagnosis from treatment. There is such a thing as over-treatment, but there is no such thing as over-diagnosis. I have always felt that the USPSTF was quite condescending and paternalistic in assuming that patients, after finding out the prostate cancer diagnosis, would invariably choose surgery or radiation as treatment. Through the shared decision making process, I have found patients to be quite receptive to the active surveillance protocol. About 20-30% of my patients choose to have active surveillance. By not screening any patients, we would prevent patients from making an educated and autonomous decision regarding their health.
  15. Daniel Moon
    Congratulations on a well researched, carefully thought out, balanced consensus statement. Hopefully this begins the process of a more rational interpretation of available evidence. This goes some way towards advising primary caregivers that they can utilize the proven benefits of PSA based screening yet avoid the over diagnosis and over treatment of insignificant malignancies.
  16. Declan Cahill
    The Melbourne statement is a clear and helpful piece of guidance on the position of prostate cancer screening. Statements 1,2,3 & 5 are uncontentious whereas statement 4 is perhaps a position to be explored more thoroughly.

    Clearly the key to modern PSA screening is active surveillance of low risk disease. Doing that effectively, safely and sympathetically is the key. We could do with a consensus on the description of low risk prostate cancer that liberates men from the stigmata of the diagnosis such as that levied by insurance companies. If we believe low volume 3+3 is is not malignant we should change the name as bladder cancer did with PNLMP.
  17. Hashim Uddin Ahmed, UCL
    Thank you for producing this statement. It has clearly taken some considerable effort and time and such endeavours are to be congratulated. I do have some issues with parts of it though. I will refrain from ad hominem attacks because these are unhelpful and do everyone's position and/or cause a disservice. Everyone has a legitimate right to speak on this topic including all members of our multi-disciplinary teams. Of course, we are all conflicted somehow - whether salaried or obtaining large research grants in prostate cancer or private practitioners, we all have much to gain/lose depending on the direction this field takes.

    Whilst many of us may yearn for clarity, from family practitioners to specialists, this area is controversial and there is much that is not clear. That is just the way it is and reflects the evidence in its entirety.

    Further, I see no evidence of a systematic review of the literature and due consideration given to evidence that conflicts with the statements made. This is clearly a position statement and not a true consensus statement which usually weights the level of agreement and highlights areas of difference and contention. In addition, the selection of participants needs to be made more explicit - in saying this I do not question their knowledge and right to make such statements, but rather for the reader to understand 'why' these eleven experts.

    More specifically,

    Statement 1. Screening men aged 50-69. This seems to be based on one study. I am disappointed that the authors did not see fit to raise some of the conflicting evidence, regardless of whether they think the other level 1 evidence is as strong as the European screening trial. It is also disappointing that the Gothenburg report is always specified as a separate trial when in fact it was part of the European one. Yet, many of the European investigators are often very sensitive to the argument that the ERSPC was a meta-analysis of lots of smaller trials based on regional country basis. Shared decision-making is often used as an excuse to continue as we are. All medicine should be shared decision-making but it is no excuse to continue doing what we are doing in prostate cancer diagnosis and treatment.

    2. Uncoupling treatment from diagnosis. This is admirable and whilst pockets are behaving sensibly, the vast majority are not and still treat large proportions of low-risk disease with treatments that cause harm and for little to no benefit. The authors, rather than tackling this head-on, allow a get-out clause for such over-treatment "Active surveillance strategies need standardization and validation internationally to reassure patients and clinicians that this is a safe strategy." Do NONE of the authors believe that active surveillance is a safe strategy?

    3. Multivariable approach to screening. We have dozens of risk calculators and more come out all the time yet they are not routinely used on a widespread basis. This does not clarify the situation for family practitioners. I think almost all prostate cancer papers end with 'biomarkers will help in the future' - it is a very disappointing get-out clause yet again.

    4. Screening younger men. The knee-jerk reaction to this, whilst based on very good cohort studies (not RCTs), is not the negative predictive value of a PSA threshold below approximately 1, but what is likely to be even greater over-investigation with harmful TRUS biopsy and over-diagnosis of harmless benign-like lesions in those that have a PSA above 1. This is not how the study's findings should be used but this is the way it will be.

    5. Screening in the older man. Although this makes intuitive sense, the weight of evidence is poor. I am surprised, with the list of authors, that there was not some dissent, at the very least.

    I trust the statement will be subject to rigorous and strong peer review by the BJUI, if submitted there.

  18. Jo Milios
    Having just attended the APCC /World Congress pcwc#13 & sitting in the audience during the delivery of this consensus (with Prof Patrick Walsh at the helm & A/Prof Declan Murphy beside him), the combined 30 years of Prostate Cancer experience from ALL contributors was something to behold. (& including the opinions of Dr Ian Haines). From the Father of Radical Prostatectomy to the Irish lad with passion & twitter zest, it appeared to me that the priority was nothing less than patient care. All the arguments are valid. Total years of Prostate cancer experience in that room would no doubt stretch many times around the moon...(no data to support this yet)!
    But what were we doing here & why? .....

    So last night, walking thru the streets of Melbourne I decided to ask our most important audience for an opinion on the new consensus...The average Joe Blow..... Data: 10 men somewhere between 40-75yol, all varying nationalities.
    Results: 6 had heard about it. All felt relieved. 2 others weren't interested. Last 2 were keen to look it up.
    60 % relieved
    20% curious
    20% disinterested

    Conclusion: Up to 80% of the average man on the street feels relief for this knowledge being available & that the 'clarification that is INCLUSIVE of them & their right to be involved in the decision making process with respect to their own health'... Rather like a pregnant woman getting a nuchal fold Ultrasound for Downs Syndrome .....or a Pap smear. (Not all my friends get those)!!

    As a physiotherapist in Mens Health I see all of the scenarios explained in research & conferences. This past week alone - from a 37yol who had a baby 4/12 after his LRP, continent (NO PADS) & on ED meds 3/52 post-op...to a 83yol gent with just as much youthful spirit for survival, hospitailsed for metastatic prostate disease causing paralysis.... Doesn't mean that any bloke should be denied UNDERSTANDING & open communication about choice for SCREENING or not...

    So from a female perspective & flag-barer for Mr Joe Blow, it is perhaps time to put down your swords boys, for the average man just needs a common sense & compassionate approach. Ask any bloke to perform a pelvic floor contraction & that's confusing enough- especially as they usually don't even know they have one!!!....

    I think we should commend, accept, respect and move on from this issue & invest our very passionate energies into survivorship ... Thank you to the global Urological community for working so hard , for so many, you have invested much...but there are some brittle bones, some smallish penises, a few cranky partners & lots of wet jocks still hanging around...

    So as they say in Australia, 'bloody oath mate', let's just get back on the job & continue to serve our fellow man in the street. Ain't that what we ALL originally set out to do??? We have a position of privilege here folks, lets use it not abuse it!

    Thanks to all for a marvellous conference. I came here to learn from the best & I did. Now I will take ALL of it back to the average man & his partner on the street in Perth, Western Australia.

    For each individual has a right to express & seek out their own health care. Even you & me.

    Regards, respect & gratitude to all.
    Jo Milios
  19. Mahesha Weerakoon
    I would like to convey my gratitude and offer congratulations, to the panel of experts, for their time, thoughtfulness and careful consideration in executing a well- informed, succinct statement to address the controversies surrounding PSA testing. With no doubt, this clarity will help health care providers and patients’ alike in decision- making and allay any confusion or anxiety surrounding the controversies. Fantastic effort!
  20. Nathan Lawrentschuk
    Dear All
    Sensationalist comments and mistruths fail to take this debate forward. We are first and foremost doctors trying to do the best for our patients.
    If we abandon PSA testing as some suggest then we will get many men needing chemotherapy and even radiotherapy- with systemic disease- do we as urologists then accuse medical oncologists of having a vested interest in having no PSA testing because they stand to benefit? No. So perhaps medical oncologists should also be excluded from the PSA debate as they have a vested interest. What's good for the goose is good for the gander.
    So lets leave financial and other ridiculous commentary out of this debate and stick to the science.

    A/Professor Nathan Lawrentschuk
  21. Adam Landau
    It really would be ideal if specialists could create a position statement that was universally agreed upon, and based on a perfect test.
    We have neither.
    What seems to have been generated in this statement is a clear, logical, easily understood approach to an imperfect test. A test used to help diagnose a disease that causes pronounced morbidity.
    So many of elements of the recently held Prostate Cancer World Congress demonstrate a desire to minimise morbidity, if able avoid treatment, if necessary treat with an intent to cure, and as often as possible inform men and give them choice. The presentations were often given by the people involved in producing the psa statement.
  22. Christopher Bayne
    Bravo on the most clear-minded, level-headed statement published to date. Number 2 is the most important recommendation of them all. The prevailing criticism of CaP screening is that the cancer is slow-growing and unlikely to affect life trajectory. We need to separate ourselves from this notion as it is dangerous and, frankly, naive.

    The diagnosis of high risk prostate cancer is vital to patient survival. Furthermore, patients are not created equal with regard to prostate cancer risk.

    Your statement is the only one to date that draws these distinct lines in the sand.
  23. Helen Nicholson
    As a Urology Trainee, I am often asked by patients as to whether they need their PSA tested and what exactly it means. I'm sure I am not alone, and as is evident in the above discussion, in saying that the literature surrounding the use of PSA is at times confusing, particularly when trying to translate into layman's terms for the benefit of the patient. I always tell my patients that it is an imperfect test, as are many tests used for diagnosis, and that we use it as a piece of the puzzle, not the whole. I also explain that the benefit of a single PSA remains contentious, rather we are interested in the trend of the PSA over time.

    A consensus guideline on PSA testing is never going to please all-comers and I suspect we will continue to debate the subtleties until well into my career. However, a consensus guideline is such an invaluable tool for clinicians, particularly for those at a primary care level, or those such as my self, in junior years of training. It gives us a practical basis upon which to guide our decision making process. I agree with many of the previous comments that Statement 2 is an invaluable addition to the guidelines, as Australia in particular has such a significant proportion of men on active surveillance programs. All in all, many thanks to the Brains Trust who put together these guidelines - a sensible and standardised approach to PSA testing can only benefit our patients in the long run (and make my life a lot easier!)
  24. Helen Freeborn
    A timely and concise document. Many thanks to the authors of the Melbourne Consensus Statement. As a junior Uro trainee in regional Australia, I am often asked to comment on this very topic. This Statement from industry leaders is very helpful. I will be saving this link and forwarding when asked.
  25. Mark Frydenberg
    The Melbourne Statement is a balanced consensus statement, and as its conclusions are largely consistent with the position statement of Urological Society of Australia and New Zealand (2009), a point that has already been acknowledged on the USANZ official website. A formal process is underway in Australia which hopes to provide a truly multidisciplinary statement regarding PSA testing including committee members from USANZ, medical and radiation oncology, Prostate Cancer Foundation of Australia, Cancer Australia, consumers, College of Pathology, College of GPs amonst others so a consensus is reached amonst non urologists as well as urologists and as a binational organization of urologists we look forward to our ongoing contribution to this process.
  26. Rustom Manecksha
    The Melbourne Consensus Statement is a thoughtful document, backed with high quality evidence that addresses many issues surrounding PSA testing in a clear, concise and helpful manner. I felt statement 2 - "Prostate cancer diagnosis must be uncoupled from prostate cancer interevention" - to be particularly important. In the midst of the muddle that is the PSA debate, the clarity that this documents brings is very welcomed and the panel is to be congratulated.
    Rustom Manecksha
    Urologist, Dublin
  27. Todd Morgan
    Let me add another strong voice of support for The Melbourne Consensus Statement on Prostate Cancer Testing. This is an important, straightforward document that had me nodding in agreement throughout. It is clear that this panel of international experts set out to create a series of rational statements that in no way overstep the current state of PSA screening evidence while maintaining focus on minimizing death and suffering from prostate cancer. Congratulations.
  28. Karen Price (@brookmanknight)
    Its such a tough call. I do applaud the Respectful discussion.
    As a GP I have put my thoughts into a blog discussing the difficulties relating to different colleges including our own and position statements when we are faced with the individual in our consulting room. Whether or not they ask the question, which they often dont and the hand wringing and worry beads that occur on the basis of that patients gender and age group.

    Thanks for bringing the discussion forward.
    Karen
  29. George Koufogiannis
    Congratulations to the stellar board for the research, construction, content, delivery and distribution of this timely consensus statement.
    The points put forward will grow/alter as evidence grows and as Prof Frydenberg has eluded, a multidisciplinary position is on its way.
    I, for one, am grateful for this invaluable resource.
  30. Sinead Murphy
    Thanks to all involved for bringing clarity to a difficult area. This is an extremely useful guidance for use by GPs, certainly in the Irish setting and presumably all countries where the vast majority of health interactions of the average male are with his GP, not a Urologist. Consultants will only see the tip of the iceberg, so it is the GP who gets asked on a daily basis by men aged 30-80 'Can I have my psa checked'. Now we can easily adjust our answer with the help of this statement, and know we are giving good evidence-based advice.
  31. Matthew Hayn (@matthayn)
    The USPSTF flatly stated that prostate cancer screening is harmful to men. I would argue strongly that denying prostate cancer screening to men is equally if not more harmful. There is epidemiologic and modeling data that supports this notion. The Melbourne Consensus Statement on Prostate Cancer provides reasonable, straightforward recommendations on prostate cancer screening that are data driven.

    In this era of SDM (shared decision making) the patient actually needs to have a decision to make. Unlike the USPSTF statement, this Consensus Statement allows that shared decision making to actually take place.
  32. Jeremy Grummet
    I wholeheartedly endorse the consensus statement. It is imperative that, as clinicians who care for prostate cancer patients, we adhere closely to its principles so that we can no longer be left open to the justifiable criticism of overtreatment of harmless low risk disease. We should not be satisfied with 40% of low risk patients undergoing expectant management in Australia (in fact, just state of Victoria, Australia - ?rate in rest of Australia) as this means that most low risk patients are still being unnecessarily treated. We should be aiming for active surveillance in >90% of low risk patients. Only then can we truly justify ongoing PSA testing so that we can give our patients the best opportunity to detect harmful higher risk cancers while they are still curable.
  33. Roger Kirby
    It's terrific that the Melbourne Consensus has stimulated so much healthy discussion. I have been involved in the debate about PSA since it's clinical introduction in the early 1990's. Does PSA stand for Providentially Sent Antigen, or is it a Promoter of Stress and Anxiety? I congratulate the Declan and the Melbourne Consensus Panel on their endeavours, but I also welcome the discussion. Would we really expect a $20 blood test to tell us who does and who does not have life threatening prostate cancer? The answer, in my view, is to use PSA intelligently as a useful decision tool, but, importantly, continue the search for a better marker which has greater sensitivity and specificity.
  34. Andrew Tan
    This statement contributes a sensible and workable approach to the thorny issue of PSA testing. I think it represents the current working practice of most Australasian Urologists and successfully negotiates a middle ground between the extremists on both sides who either want to remove every prostate, no matter how low the risk, and those that pretend that Prostate Cancer is not a significant disease.
    We need to shelve the shrill rhetoric, and stick to the science. Our patients will thank us for it.
  35. Jane Crowe
    As a GP who has is regularly asked by men whether to be tested for prostate cancer or not I find the Melbourne Statement to be a clear and helpful, brief, up to date summary of the evidence that can be easily incorporated into the GP -patient "shared decision making" discussion.

    Consensus statement 1- I am pleased the recommendation also mentions the reduced incidence of metastatic disease. Often the debate about whether to test or not is based on mortality figures and does not include those who are still living with metastatic prostate cancer often with a significantly reduced quality of life.

    Consensus statement 2 is very helpful in explaining and reassuring men with low risk cancer that they can be monitored closely with Active Surveillance and that radical treatment (and the effects of ED and incontinence that the man is often very concerned about) can be delayed.

    Regarding Consensus Statement 4 , it will be important to stress to Primary Care Physicians/GPs that PSA testing in a man in his early 40s is not for screening at 40 but for "risk stratification" as outlined in the explanation.

    This is a helpful statement. I would ask that it is regularly updated as new evidence emerges in the ever changing landscape of prostate cancer testing and treatment.
  36. Helen Crowe
    This consensus statement is a breath of fresh air in a previously very confusing debate, and should provide assistance for all health professionals when counselling men about their prostate cancer risks and whether or not to undergo testing.
  37. James Duthie
    Admirable. The argument about unnecessary anxiety really needs some perspective. We rob our patients of their autonomy & re-pave the path of paternalism by deciding that they shouldn't worry their heads about a disease that may not kill them. What about anxiety before mammography for screening? Before going to the dentist? It would be small comfort to the man dying of pelvic cancer with disseminated metastases that he is the price we are prepared to pay to prevent another man feeling anxious.
  38. Andrew Ryan (@drandrewryan)
    The Prostate World Congress was a fantastic opportunity to listen and converse with a virtually unprecedented collection of world leaders in the field of prostate cancer (clinical and research). I commend the Melbourne Consensus Statement group on taking this opportunity to put together a well-considered series of statements on PSA screening for prostate Cancer.
    As an anatomical pathologist (albeit specialising in clinical and research based uropathology), I feel somewhat under-qualified to endorse or argue against the group’s recommendations. That said, I think statement 2 (diagnosis uncoupled from intervention) is a very important addition to any statement on prostate cancer screening. The "diagnosis = treatment" paradigm has obviously created great ammunition against PSA screening, so significant that we now have a situation where some are advocating for a virtual ‘anti-screening program’ to avoid the complications arising out of the treatment. Uncoupling diagnosis and treatment should allow us to uncouple these issues that arise out of treatment. Budgetary and psychological considerations noted, most issues are based on overtreatment……not overdiagnosis. I believe we shouldn’t stop finding cancer, but instead attention should continue to focus on improving our ability to stratify patients with low grade cancers into management groups, whether this is by improved diagnostics testing and/or robust management algorithms. Anyone attending the World Congress would have appreciated that significant efforts are already going in to this.
    As a brief side point, I reject the suggestion to redefine the diagnostic terminology of low grade (Gleason ≤6) prostate cancer, including the removal of the term ‘cancer’. With all due respect to this forum, the above issues are not yet so great as to distort the background science; it is called prostate carcinoma for a good reason, fulfilling both classical morphological criteria of ‘invasion beyond a basement membrane’ as well as a more clinical definition of ‘ability to metastasize’ – we just have to get better at finding which ones will!
  39. Addie Wootten
    As a clinical psychologist working predominantly with men with prostate cancer and their families I believe the Melbourne consensus statement brings us a step closer to the much needed clarity we have been seeking.

    I agree with the focus on PSA as only one component of prostate cancer testing. This is the message I believe our community needs to hear.

    The difficult task for everyone within the multidisciplinary team will now be finding a way to support men to uncouple prostate cancer diagnosis from treatment. This is no easy task. The word cancer will certainly raise anxiety and most will immediately seek to find the treatment that will ‘cure’ their cancer. Enhanced support and counseling for the patient and their family is essential if we are going to be able to provide treatment only to those who really need it. Acceptance of, and adherence to Active Surveillance will only occur if patients are confident in this approach and fully informed. Uncertainty is the most powerful predictor of anxiety so the more we can support and inform our patients the less anxiety they will experience.

    Improved clinical models of care integrating the full multidisciplinary approach (including nurses, psychologists, physiotherapists and exercise physiologists) is much needed as is research to identify better prediction of cancer aggressiveness.
    I congratulate the team for the comprehensive assessment of the issues and a step towards reducing the uncertainty around PSA testing.

    Dr Addie Wootten; Clinical Psychologist.
  40. Minh Le Cong
    I congratulate and thank the folks who made this happen!

    As a GP in rural and remote Australia, I find the statement pragmatic and helpful. Much more than a lot of attempts in the past to try to clarify the topic!

    To me the urology community is attempting to address some of the critical problems of the past and seeking to prevent more from occuring in the future. At the same time, trying to encourage improvements in prostate cancer care.

    The debate and dissent amongst the medical community on this issue has been a great confusion to the men I know. Arguing the evidence has in many ways made it more confusing.

    What we needed is a pragmatic approach that incorporates our best evidence. This statement is a significant step forward in that regard.

    Observing the often heated debate between the pro vs con sides of the PSA testing, has been like watching 2 political parties trying to convince the voters on the merits of respective factions. It has not been helpful to frontline clinicians trying to advise men and their families. I therefore see the statement as a sign of good faith, that we can find common ground and work together into the future to actually improve patient care rather than argue for the sake of it!

    Like other commenters, I don't totally agree with some of the claims in the statement. However the spirit of the statement is on moving forward and changing our strategic thinking on prostate cancer/health. We should all be supporting that spirit.
  41. David Quinlan
    This is a fantastic blog with great contributions. It is also a very timely blog that amplifies the potential risks as well as the benefits of social media in the medical arena. I am sadly too unintelligent to fully understand the ramifications of all of the discussion above, and I am also naive enough to believe that the helpful airing of different points of view above would not be diluted by sticking to a measured approach. What immediately came to mind reading a few of the blogs was Max Ehrmann's 1927 Desiderata: "As far as possible, without surrender, be on good terms with all persons. Speak your truth quietly and clearly; and listen to others, even to the dull and the ignorant, they too have their story. Avoid loud and aggressive persons, they are vexations to the spirit." I have heard it said, "If it is not on paper,it does not exist, and if it is on paper, remember, it exists!"......now in a blog forever and in a viral format -this the risk of social media.
  42. Roderick van den Bergh
    Many men will continue to ask for a PSA test. Withholding screening for this total group may work counterproductive. A wiser alternative may be to present solid explanations of why screening should or should not be performed in an individual. This support may reduce doubts and help prevent persons to make irrational choices. There will always remain a tendency in clinical practice to do, rather than not to do a test.

    All attempts to translate the overwhelming scientific data into a set of advices for use in clinical practice should be applauded. The consensus statements provide a workable overview on the pros and cons of screening in different subgroups. Fortunately enough some space will always remain for a personal interpretation of the available data. All experts on this subject share a bias: Aiming for best prostate cancer care.

  43. Mickey Maklin
    I have friends and family that required prostate surgery that was first detected thru PSA testing. I'm against dropping this procedure in its' entirety. I believe the doctors and research scientists should pursue improving the schedules for PSA testing with consent from patients.

    Until an improved testing program is developed and accepted the cost for the PSA testing is certainly not expensive and, I for one, would continue paying for this procedure as long as my doctor recommends it.
  44. Derek Birch
    Good afternoon,
    As a PC survivor aged 71, I would like to comment briefly from the position of a patient rather than from the Medical Profession.
    Having had annual PSA tests for at least 10 years, with a consistent level below 4, a test in June 2011 showed approx. 4.8. My very proactive GP insisted that I see a specialist, who did a DRE and prescribed another PSA test in 4 months. That test result was further elevated and my specialist performed a biopsy in November which indicated if I remember, 7 positive samples, one of which was close to the edge of the gland. With my wife we had a long discussion on options. As far as I was concerned, there was only one. An MRI seemed to confirm that the adjacent lymph gland was not compromised.
    I had a Radical Prostatectomy in early Feb. 2012 Immediately after and since the operation, I have had no incontinence, but my libido is very low. However, I am alive and kicking, I can walk confidently 10 km or more and feel as fit as I ever was. I also have a totally supportive wife.
    A colleague of mine who is 10 years younger, had a very similar diagnosis in the same month as mine, but who chose to watch and wait for 12 months. He subsequently had a Radical almost 12 months to the day from my operation. His result is not good as the lymph gland was by then compromised and he is now undergoing therapy. I don't believe that his prognosis is likely to be as good as mine.
    I am positive that without having had regular PSA tests which established a pattern, or the immediate response of my GP and the intervention of a specialist because of whose manner and experience I trusted implicitly, I would not be able to say that I believe that it is now all in the past.
  45. Troy Gianduzzo
    The panel are to be commended on a thorough and well balanced series of recommendations. These go a long way to countering the misinformation that exists in this debate. At 6 year follow up the PLCO study is meaningless and yet the USPTF fail to recognise this very simple, very fundamental clinical fact.

    Congratulations to the panel for putting together these recommendations.
  46. Brian Bornstein
    Hi, I saw some comments on new screenings tools and developments; in addition to PSA tests. Phi test, biomarkes, improved imaging, MRI, Polaris, focal treatment/electroporation etc. These are all interesting sounding words to a "prostate cancer diagnosis novice" like me. But do they work? Are they in use in Canada, the USA or does a patient have to fly to some remote location like ... Melbourne Australia (ha ha.... No offence. My daughter lived and worked in Auz for 2 years and loved it. Great country and people!!!!!) to get new leading edge diagnosis tools???
    Cheers,
    Brian
  47. Thomas Little
    As a Prostate Cancer survivor who would not have been diagnosed or treated under the USPTF guidelines, the Melbourne Consensus statements fortunately include me. Establishing a PSA baseline followed by regular PSA testing certainly helped me in the early diagnosis of my Prostate Cancer. And as a grandfather with two grandsons who just might have inherited some unwanted genes, it is extremely important to me that the right set of guidelines are adopted and followed.

    Thanks to all involve in Melbourne.
  48. Marnique Basto
    As a Urology trainee who’s taken some time out to conduct clinical research in prostate cancer, I am absolutely blown away by the collective and multidisciplinary think-tank at the helm of these guidelines. These are the names I read on a daily basis in prostate cancer literature. From a trainee’s perspective they are clear, concise, founded upon the highest level of evidence available and undoubtedly backed by world leaders in the field. The multidisciplinary expertise here is unquestionable and if Dr Martin Gleave alone has published >340 papers in prostate cancer with an H-index of 68, I shudder to think of the collective academic record between all signatories.

    In the weeks since this Consensus on PSA testing was released it has reached far and wide with an overwhelming consensus of support. At a glance, these comments above stem from Canada, USA, Ireland, England and Australia. Represented among this bunch are Urologists, Oncologists, Pathologists, General Practitioners, Psychologists, Nurses, Physiotherapists, numerous Urology trainees and fellows from Australia and the USA, the CEO of Prostate Cancer Foundation of Australia (PCFA), Uro-Oncology clinical researchers and most importantly patients including ‘Thomas Little’ who’s early prostate cancer was detected due to the rationale used in ‘Consensus Statement 4’.

    Irrespective of the stance these comments take, the use of a blogging medium here is genius. There is no other medium out there where such a diverse group of people can all contribute to the one topical academic discussion. As a trainee these comments are invaluable in understanding the intricacies of the debate from all angles. The driving forces behind this statement and its dissemination should be commended for tackling such a difficult issue and delivering it to the world in real time.
  49. Matthew Bultitude
    Marnie - I certainly agree with the last paragraph about blogging. It is a fantastic medium for real time discussion on topics with dissemination of information using other forms of social media. This has been a very popular topic.

    With regards PSA testing, it certainly is controversial and the result of the BJUI poll shows the split in views with 59.5% supporting the Consensus Statement - but meaning 40% don't. These results are potentially very skewed but the respondents are also likely to be urologists demonstrating that even amongst urologists there is no consensus.

    The argument rumbles on ... but if we can't agree, how confusing must it be for patients! Maybe there should be a 6th Consensus Statement about the downsides and risks of PSA testing to give more balance if this statement is to be read by patients.
  50. Alan Barlee
    I note the relevant input of two PCa survivors to this blog (of 55 so far). I am another, still alive and kicking strongly 12 years after my first elevated PSA, positive biopsy and RP with negative margins (albeit managing Stage 4 disease for most of that time).

    I add my congratulations to the team that organised this event and got these consensus statements out, and I particularly acknowledge the deep experience and commitment of those experts who participated . As far as they went, the Melbourne Statements are clear, concise and unambiguous, and are an honest reflection of the research literature. However, there seem to be a few important gaps.

    1.The age range of 50-69 takes no account of familial and ethnic risk factors, where the literature seems to justify an earlier start to regular PSA testing (e.g. age 40), nor does it indicate a frequency of testing, either with or without these risk factors.

    2. The role of the DRE seems to be downplayed, rather than being promoted as an routine adjunct to the PSA test.

    3. There is no mention of the key purpose of active surveillance, i.e. monitoring the PSA kinetics, in order to distinguish BDH or stimulation-induced PSA fluctuations from an underlying and persistently upward PSA trend. Depending on the rate of increase, such a trend may warrant diagnostic imaging ( e.g. colour doppler ultrasound, (feroheme -MRI, C11-choline PET/CT) and only then a targeted TRUS (or better) biopsy, in order to get a definitive Gleason grade. This is the minimum information that is needed to guide the choice of continued surveillance vs. medical intervention, with all its side effects and risks, and it puts meat on the bones of uncoupling diagnosis and intervention.

    Unless these matters are positively addressed, GPs, urologists and their untreated patients will continue to have uncertainty about how best to use PSA testing in this setting.

    4. PSA (with PSADT/PSAHT) continues to be an exquisitely explicit and sensitive marker to track the effect of medical treatments that may follow diagnosis, particularly for metastatic disease. This needs to be acknowledged in the preamble, in order to further counter the bad press that PSA testing has been getting.
  51. Chris O'Neill
    The elephant in the room that is being missed here is how does the treatment ratio (treatments per life saved) of the current PSA test -> biopsy -> prostatectomy strategy, compare with the preventative strategy of giving prostatectomies to every man before there is much risk of prostate cancer even starting, say, at the ages of 45 to 50?

    Considering that there were 72,957 Australian male deaths in 2010, if all of those men had been given prostatectomies by the age of 50, then the vast majority of the 3,224 deaths from prostate cancer could have been prevented. Thus a treatments per life saved ratio approaching 23 to 1 could have been achieved.

    This compares with the treatments per life saved ratio of 48 stated in the Randomized European Study.

    So the question is, if a life-saving strategy that requires 48 treatments per life saved is acceptable, then why is a life-saving strategy that may require as few as 23 treatments per life saved being ignored?
  52. David L. Keller, M.D.
    There really is no interpretable level 1 evidence regarding PSA screening. The best study was Goteborg, but even it had a "screened" group in which 24% of the men never had a single PSA drawn, yet these men and their bad outcomes were counted by Intention-To-Treat (ITT) analysis as a failure of PSA screening. The number needed to screen to prevent one death from prostate cancer was 293 by ITT, but only about 230 men were actually screened for each prostate cancer death prevented. The worst study, PLCO, had a "control" group in which 52% of men received PSA screening from their private doctors outside of the study protocol, and only 86% of the men randomized to screening completed the protocol. PLCO had only a 34% difference in PSA screening status between the allegedly screened and control groups, which should ideally have been 100%. As a result, PLCO tells us nothing about the biological effects of PSA screening, yet is it cited as proof that PSA screening does not work. The incontrovertible fact is that deaths from prostate cancer went down 40% in the US during the years after PSA screening was widely adopted, with no other plausible explanation than PSA screening. This is rock-solid observational data which trumps contaminated data from flawed controlled trials.
  53. Ian Haines
    Please note David that the following age-adjusted death rates (AADR) in the USA from 1930 to 2006 show a reduction for colorectal cancer in both sexes, a reduction for stomach cancer in both sexes, a reduction for uterine cancer and a reduction for breast cancer in women. The data reveal an increase in AADR for prostate cancer in the same period of time. 
    https://m.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-026238.pdf
    • David L. Keller, M.D.
      Thank you, Ian. I would guess that the drops in AADR due to the GI cancers and uterine & breast cancers are due to better treatments in 2006 than in 1930. But PSA testing was introduced during the modern surgical era, when surgeons were already quite good at removing malignant tissues for curative purposes if done early enough. PSA saves lives by detecting CaP before it becomes symptomatic, which is too often too late. Recent advances in CaP surgery have yielded reduced harms from surgery, such as incontinence & impotence, but not in cure rates, since uro-oncologists have been great at curing malignancy by removing it (if early enough) for years. Does your opinion differ?
  54. Robert Princenthal, MD
    I feel that the authors are to be commended on providing compelling data and evidence to refute the flawed conclusions of the USPSTF guidelines. Here in the states, since that statement has been published, the primary care docs have reduced the number of men being screened with PSA, fewer men are proceding to biopsy, and fewer men are having radical prostatectomy. Have the cancers disappeared, or will we see are rash of men presenting in 5-8 years with advanced, late staged disease?

    I wish the authors included the powerful benefit of high quality prostate MRI, using the Pi-rads structured reporting format. Men at risk with rising, or elevated PSA should then have a prostate MRI. Many times the MRI will reveal a 'clean' gland, and the negative predictive value of excluding a biologically significant cancer, defined as 0.5cc vol of GS 6, or a smaller 4 component is over 92%. For men who are found with a Pirads 4, or 5 lesion, the cancer detection rate is over 85%, with significant grade tumors found. MRI opens the way to fewer needles/higher yields, fewer harms, and improved outcomes. We need more access to high quality prostate imaging, interpreted by skilled radiologists to help men be triaged appropriately. The tides are turning, and I feel we can refute the flawed logic of 'harms' from the US task force.

    I am a private practice radiologist in Southern California, who has been performing prostate MRI and targeted biopsy since 2009.

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