Calls for a prostate cancer screening pilot grow, but do the risks outweigh the benefits?

Bruce Hayward (left) died from prostate cancer in November 2019. His wife, Kristine Hayward, this year presented a 30,000-strong petition to Parliament calling for an early detection programme.

The Cancer Society and Prostate Cancer Foundation both support piloting prostate cancer screening. The foundation says screening will save lives and health costs - but a recent briefing from Te Whatu Ora, obtained under the Official Information Act, outlines why it isn’t supported. What does Health Minister Dr Shane Reti think?

Trialling prostate cancer screening in a region or two is now backed by the Cancer Society, which says the “controversial” idea is complicated but worth testing.

Recent high-level official advice, obtained by the Herald, concluded there’s not enough evidence that the benefits of screening would outweigh the downsides, including people undergoing surgery for a disease that ultimately wouldn’t harm them.

Dr Kate Gregory believes over-treatment and problems with the accuracy of testing are major obstacles, and that's why prostate cancer screening hasn’t been done here or overseas.

Cancer Society medical director Dr Kate Gregory says such over-treatment issues and problems with the accuracy of testing are major obstacles, and that is why prostate cancer screening hasn’t been done here or overseas.

But she said that recently in Europe a new protocol had helped refine who ultimately went on to be treated, by using MRI scans and factors like a family history of the disease, as well as the traditional prostate-specific antigen (PSA) test.

“I think with that new approach to screening, we are supportive of a trial looking into it [in an area or two]. But obviously, with any screening test, you want to make sure you aren’t doing harm, and you are actually saving lives.”

Prostate cancer screening was a “controversial” issue, Gregory said. Any change would need an appropriate workforce and resourcing, particularly given there are already worrying delays for MRI scans in New Zealand.

“That is the kind of information you get from a trial.”

Why prostate cancer screening isn’t supported by health officials

The Prostate Cancer Foundation has led lobbying for a screening pilot, including by writing to previous Health Minister Ayesha Verrall.

It wants an initial pilot in at least two areas for all men aged over 50, or 45 for those with a family history, and 40 for those with the gene variant BRCA2.

Verrall asked for a briefing, which was sent in July, and signed off by Dr Jane O’Hallahan, the clinical director of Te Whatu Ora.

The best test for prostate cancer is a blood test measuring the amount of PSA - a protein produced by cancerous and noncancerous tissue in the prostate, which is a gland that sits below the bladder.

High levels of PSA can indicate cancer, but also many other conditions, including an inflamed prostate.

In the briefing, released under the Official Information Act, O’Hallahan noted that screening would involve offering a test to people with no symptoms and who are otherwise healthy.

“There is insufficient evidence that the benefits of a national, organised population health prostate cancer screening programme outweigh the harms.

“The PSA test is a poor test for prostate cancer in men aged around 50 - 70 years. The test is not sensitive or specific enough.

“Depending on the PSA threshold selected, there are too many false negative and false positive results …about 75 per cent of men with an abnormal PSA result do not have prostate cancer - a false positive result. About 15 per cent of asymptomatic men with a normal PSA result will have prostate cancer - a false negative result.”

A biopsy is needed after an abnormal PSA result, the briefing stated, and harms from a screening programme would include the complications from this procedure and any subsequent treatment.

“Of men with a positive biopsy, 20 - 50 per cent will be diagnosed with cancer that will not have caused any harm (overdiagnosis), which can lead to unnecessary treatment.

“For men undergoing surgery [radical prostatectomy], one in five will develop long-term incontinence, and at least two in three will experience erectile dysfunction.”

More than 447,000 PSA tests were done in New Zealand in 2018/19, including for men with symptoms or risk factors, and surveillance of those with diagnosed cancer.

Parliamentary select committee inquiries in 2011 and 2019 did not support a national screening programme, the briefing noted, and more studies were needed into the changes being explored in Europe.

“Lithuania is the only country in the world offering universal population screening for prostate cancer,” the July briefing stated.

Last month, the national screening advisory committee - part of Te Whatu Ora - reviewed the current international evidence and concluded: “There is insufficient evidence to recommend a national prostate cancer screening programme at this time.”

The Prostate Cancer Foundation’s position

Prostate Cancer Foundation president Danny Bedingfield said the true value of population screening cannot be known until a pilot is run.

“Over 700 men die of prostate cancer every year in New Zealand … it isn’t just old men. I was diagnosed at 37. There are a lot of people dying of this disease, still with young children,” says Bedingfield, now 48.

Danny Bedingfield, president of the Prostate Cancer Foundation NZ, says screening is badly needed.

“Significant advances in technology and improved diagnostic methods mean previous risks have been reduced, and the latest research clearly shows that a comprehensive early-detection programme holds the promise of halving mortality from the disease.”

Modelling for the charity, done by the NZ Institute of Economic Research (NZIER), estimated a pilot in Waitematā (West and North Auckland) and Tairāwhiti, including Gisborne, would cost $6.4 million over four years, and potentially result in over $100m in cost savings and half a billion dollars in health gains, over the course of the participant’s lives.

The foundation also wants the Government to consider funding more diagnostics, including specific MRIs, biopsies and PSMA-PET scans, so men with advanced disease don’t go through unnecessary and radical treatment.

Health Minister Shane Reti told the Herald he was expecting advice from health officials on “a range of health priorities, including the suite of national screening programmes”.

“Targeted screening can be incredibly successful in picking up early signs of disease and reducing the likelihood of serious illness developing.”

Kristine Hayward presented a petition, signed by 30,000 people, calling for government action on prostate cancer. Photo / Neil Mackenzie

Bruce Hayward died from prostate cancer. His wife petitioned Parliament to help others

Hamilton nurse Kristine Hayward’s husband, Bruce, died from prostate cancer four years ago, aged 66.

He had regular prostate-specific antigen (PSA) tests done as part of check-ups with his GP, and these showed his levels were rising, which can be a warning sign for cancer.

However, he didn’t think the condition would be aggressive, and his doctor agreed that keeping a regular watch on his PSA levels would be okay.

By the time Bruce, also a registered nurse, was referred to a specialist the cancer had spread and couldn’t be treated.

Kristine believes the outcome may have been different, had her husband received testing and follow-up through a proper, organised screening programme.

She began a petition for an early detection programme, which gathered more than 30,000 signatures and was presented to Parliament in July.

Current testing and the response to results is uneven, underfunded and disorganised, she told the Herald.

Screening could be leveraged off existing infrastructure for breast, cervical and bowel screening programmes, she said, and advances in technology and the approach emerging in Europe showed risks including over-treatment could be managed.

Bruce is terribly missed by his friends and family, including his two children and six mokopuna.

“I don’t want anyone else to go through the hell that I’ve gone through,” Kristine says of losing her “soul mate”.

“He had a lot to offer, not just his family but also society. He volunteered in a lot of initiatives.

“He’d light up a room. He was very intelligent, and a force to be reckoned with. If he saw a problem he would address it. But, like a lot of men, they leave themselves last.”

Nicholas Jones is an investigative reporter at the Herald. He won the best individual investigation and best social issues reporter categories at the 2023 Voyager Media Awards.