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Increased patient demand for prostate test has serious implications for cancer services

Male patients are increasingly demanding PSA tests for prostate cancer, despite lack of evidence that they are effective, according to a survey of more than 700 family doctors published in the November issue of the urology journal BJU International.

Researchers from Queen’s University Belfast and the Eastern Health and Social Services Board discovered that more than two-thirds of doctors (65 per cent) said that they provided PSA tests on request.

They did this despite the fact that the UK National Health Service Executive and the UK’s National Screening Committee don’t recommend routine screening for prostate cancer, in the absence of symptoms, using PSA (Prostate Specific Antigen) blood tests.

“Increased on-demand PSA testing represents a major pressure on family doctors and has serious implications for prostate cancer investigation and treatment” says co-author Dr Jackie McCall, Specialist Registrar in Public Health Medicine at the Eastern Health and Social Services Board.

“Clinical evidence suggests that PSA testing may not improve survival or quality of life and might cause more harm than good, to patients and services alike."

The team surveyed all 1067 family doctor practices in Northern Ireland and matched their responses with a regional PSA testing database.

More than two-thirds of the doctors surveyed (704) responded to the postal questionnaire, which explored their personal profile, the profile of their practice and their PSA testing behaviour.

A detailed analysis of the results revealed that there were a range of complex factors that influenced whether family doctors carried out PSA screening. These included:

• 49 per cent of doctors were aware of the national guidelines for PSA testing, but that awareness did not influence testing levels.

• Tests were more likely to be ordered by full-time male doctors who had been practising for 21 to 30 years and by those who worked in rural practices.

• 13 per cent of doctors had held a postgraduate post in urology, but this did not affect their testing behaviour. And working in an accredited training practice was associated with lower testing levels.

• Opportunistic PSA testing is being carried out on men who consult their family doctor about unrelated complaints. 47 per cent of doctors reported that PSA testing had previously picked up prostate cancer in patients with no symptoms and 51 per cent said this influenced their practice.

• Doctors were also more likely to test men with a positive family history of prostate cancer.

• Only half a per cent of the doctors surveyed reported a specialist interest in male health, despite prostate cancer being the commonest male cancer and current drives to improve awareness of the disease in primary care.

Data from all the first PSA tests ordered by doctors during the survey period (2003-2004) were matched with the questionnaire responses and analysed to investigate their association with variables such as gender, age, location of practice and awareness of guidelines.

More than 15,000 PSA tests had been ordered – an average of 11 per doctor.

34 per cent of the respondents worked in an urban practice, 24 per cent in a rural setting and 42 per cent in a mixture of the two. Seven per cent worked on their own and 32 per cent had five or more partners.

“Our research shows that merely providing family doctors with guidance is not sufficient to influence patterns of PSA testing” adds co-author Dr Gerard Gormley, a Senior Lecturer in the Department of General Practice at the University. “They need better training in this area so that testing can be targeted more effectively and that patients can be kept better informed and counselled if testing is indicated.

“Finding out what makes family doctors carry out PSA tests is an important step in this process. Cutting the number of unnecessary PSA tests carried out by family doctors will lead to more effective referrals and this will play a key role in reducing hospital waiting lists so that urgent cases receive the priority they deserve.”

BJU International’s editor Professor John Fitzpatrick, from University College Dublin, Ireland, says that that the paper makes an important contribution to the ongoing debate on PSA screening. "This is an excellent study which looks scientifically at the problems that may develop in the UK with the increase in PSA screening" he says.

Annette Whibley | alfa
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