Emergency and stroke physician combined consensus statement on thrombolysis for acute stroke

The latest NZMJ contained a consensus statement from the NZ faculty of ACEM which differs slightly from the ACEM statement. It is longer than the ACEM statement and fills out some of the brief statements. As with many of these documents many of the statements are fairly obvious.

Small difference is noted in the section regarding the informed consent for thrombolysis. Suggesting that it should be discussed by someone with sound knowledge of the benefits and harms. This doesn’t mention or require patients are informed of the disagreement amongst medical professionals of the risks and benefits of the intervention.” A minor but possibly significant difference.   

Another interesting statement is around the timing of thrombolysis with the group unable to come to a consensus around the utility of thrombolysis in the 3-4.5 hour group.

So here is their statement:

Consensus Statement:

  • Stroke thrombolysis with intravenous alteplase is applicable only to a minority of stroke patients and should be seen as a treatment option indicated in carefully selected stroke patients.
  • Patients should be selected in accordance with agreed protocols with explicit inclusion and exclusion criteria. These protocols should be aligned with the published literature and established collaboratively between emergency physicians, neurologists, stroke physicians, and other relevant stakeholders. Treatment outside of agreed criteria might increase the risk of adverse outcomes.
  • The strongest evidence for benefit of stroke thrombolysis is for patients treated within 3 hours of stroke onset. Emergency physicians, neurologists, and stroke physicians should work collaboratively to minimise treatment delays.
  • This group was unable to reach a consensus about the utility of stroke thrombolysis between 3–4.5 hours of symptom onset.
  • Inpatient stroke team pre-notification of a potential thrombolysis patient’s arrival is encouraged to facilitate rapid patient assessment and to assist with potential resource constraints in emergency departments.
  • Appropriate infrastructure should be present including timely access to neuro-imaging (CT scanning) and timely interpretation of these scans prior to thrombolysis by consultant radiologists, neurologists, or stroke physicians/delegated radiology registrars with appropriate expertise and training.
  • Informed consent for thrombolysis should be discussed and obtained by a medical specialist or delegated registrar with appropriate expertise and training in stroke assessment/management and with a sound knowledge of the benefits and harms of stroke thrombolysis.
  • There should be appropriate care and documentation of progress after thrombolysis including recording of vital signs and neurological observations according to agreed protocols.
  • Patients should be expeditiously transferred to a designated intensive monitoring ward area or Stroke Unit (ideally immediately following neuro-imaging prior to or immediately after administration of thrombolysis).
  • Services who provide thrombolysis should audit their service regularly to monitor safety and measure outcomes. Audit results should be reported routinely to local clinicians and regional stroke networks. Ideally a national database should be established to audit all stroke patients, including individuals treated with thrombolysis, to measure outcomes, with the results made available to all clinicians involved in the care of stroke patients.
  • The ongoing appropriate use of thrombolysis in stroke should be reconsidered as the results of audits, or further research, become available.

 Ref: NZ faculty statement:  http://journal.nzma.org.nz/journal/127-1392/6096/

 ACEM statement: https://www.acem.org.au/getattachment/1636cfd5-3829-4fc6-9eb2-91742f3d250b/Statement-on-Intravenous-Thrombolysis-for-Ischaemi.aspx

Prostate cancer. They just don’t get it! #movembermadness

Prostate cancer and PSA testing is an emotive subject. Sadly the press are often unhelpful in regards to this with their regular survivor stories and not discussing the harder subject matter. Now the MOH has launched a prostate cancer awareness campaign. Which leads me to the question:  When is encouraging patients to get tested a screening programme?

http://www.stuff.co.nz/national/health/9450677/Prostate-cancer-campaign-ahead

http://www.scoop.co.nz/stories/PA1311/S00503/national-prostate-cancer-campaign-a-first-for-nz.htm

Men are being urged to pick up a new booklet from their GP and complete a checklist of symptoms.

It is the first part of a $4.3 million programme to raise awareness for prostate cancer.

That aims to see men getting diagnosed sooner and improving the rate of survival. (Its called lead time bias) 5 year survival in the US for prostate Ca is 95% but 71% in the UK. driven by PSA use and early diagnosis. Overall mortality is the same.

Men are being urged to pick up a new booklet from their GP and complete a checklist of symptoms.

Prostate checklist for men

Choosing whether to have a prostate check is an important decision. You need to have enough information to make the decision that is right for you and your loved ones.

If you answer ‘Yes’ to any of the following, talk to your doctor, nurse or health professional.

  Yes/No
I am peeing more often.*  
When I pee, I have trouble getting started or stopping.*  
I have poor urine flow or dribbling.*  
I often get up at night to pee.*  
I have blood in my urine.*  
I have pain in my lower back, hips or ribs.*  
I have a family history of prostate cancer and I’m 40 years old or more.  
I am 50 to 70 years old.  
I am concerned or want to know more.  

*Answering yes to any of these points may not mean you have cancer but you should get them checked by your doctor, nurse or health professional straight away.

The check assesses your risk of having it. The check will tell you how likely you are to have prostate cancer.

Checks usually involve a blood test – called a prostate-specific antigen (PSA)

Health Minister Tony Ryall said there was a need to get a “clear message” out there.

“Patients hadn’t always been given a consistent message, and that meant fewer men were being screened than should be.” (We shouldn’t be screening!)

This push is despite the huge move back in the use of PSA due to evidence showing its futility. All NZ males between 50-70 are being asked to see their doctor, nurse of health professional straight away! (this is around 400,000 men) currently new Zealand has high levels of PSA testing with 40% of males over 50 having had a test at some stage.

Professor Nacey said. “The causes of prostate cancer were still largely unknown, and it wasn’t practical to test every man over 50.”

Even the American Urological Association has pulled its guidelines back greatly. Recommending against screening those under the age of 54 and those over 70.

“Guideline Statement 3: For men ages 55 to 69 years the Panel recognizes that the decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality in 1 man for every 1,000 men screened over a decade against the known potential harms associated with screening and treatment. For this reason, the Panel strongly recommends shared decision-making for men age 55 to 69 years that are considering PSA screening, and proceeding based on a man’s values and preferences.”

Despite these clear guidelines from “the specialists” the PSA test is being widely misused.

“Prostate Cancer Foundation of Australia survey found more than one in 10 men in their late 20s had a PSA test on the advice of a GP”

The booklet does mention the decision to have testing but then moves on to discuss all treatments and follow-up. In reality patients are being told having a PSA test is harmless and that they can make decisions afterwards. In reality once a patient has a positive PSA test the horse has bolted. The cascade of interventions has started. Very few choose not to have a biopsy which leads to further treatment for follow-up biopsy.

Should I have a blood test to check for prostate cancer?

Having a prostate check is your decision. Choosing whether to have a prostate check or not is an important decision to make.

A prostate check aims to reduce your chances of being harmed or dying from prostate cancer. While the PSA blood test and the DRE may be uncomfortable, there is no risk from having them. They do not harm you in any way.

Depending on your PSA and DRE results, you may need to make decisions about more tests and possibly treatments. The tests and treatments have benefits and risks (can cause harm). You need to understand what the benefits and risks are so you can make the right decisions for you and your family and whānau.

In summary I can’t understand why the huge push is on for prostate cancer screening. The MOH seems to be implementing a screening programme by stealth. It is not good enough for NZ men to be the guinea pigs in a trial which they do not enrol.

Finally amongst the Movember madness a number of good articles for lay people have been written including this one:

http://www.nzherald.co.nz/lifestyle/news/article.cfm?c_id=6&objectid=11150921

Ref:

Booklets an info sheets from MOH

http://www.health.govt.nz/your-health/conditions-and-treatments/diseases-and-illnesses/cancer/prostate-cancer

American Urological association.

http://www.auanet.org/education/guidelines/prostate-cancer-detection.cfm

 

The great PSA debate #pcwc13

This week in Melbourne the prostate cancer world conference was held.

The consensus statement this produced/publicised is linked below.

 http://www.bjuinternational.com/bjui-blog/the-melbourne-consensus-statement-on-prostate-cancer-testing/

I think we can all agree the PSA cat is out of the bag and has had kittens. There is no going back to Pre-PSA testing but the harms of testing/treatment are very real. What follows are a few thoughts on the statements, responses and few interesting links. Some thoughts from GP peer review.

 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.

This statement is really a push back against the US Preventive Services Task Force recommendation. The evidence base is mixed but that screen reduces the mortality and risk of metastases  at diagnosis is fairly clear . What is unclear is how much harm this screening and treatment causes. Interestingly within the statements there is no mention of harms which leads to Statement 2.

 Consensus Statement 2: Prostate cancer diagnosis must be uncoupled from prostate cancer intervention.

 This is an attempt to reduce the harms that over diagnosis and treatment cause currently. The GPs at peer review thought this aspirational statement was excellent but still remained cynical about how much this was currently occurring.

The reality that PSA testing drives a large portion of private urology work/referrals does make some uncomfortable.

 I would point you in the direction of Dr Rajiv Singal who wrote an excellent piece on this in June. (@DrRKSingal)

“In my view PSA itself is a blood test. It is harmless. It is the treatment machinery that it often initiates that potentially gives it a bite and needs careful reflection.”

http://www.bjuinternational.com/bjui-blog/early-prostate-cancer-detection-one-canadian-urologists-perspective/

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.

There are currently multiple risk assessment tools but little consensus around their use. This also reflects the benefit of DRE in addition to PSA testing. 

 Consensus Statement 4: Baseline PSA testing for men in their 40s is useful for predicting the future risk of prostate cancer.

I understand the reasons for this statement but the application of it which I have seen discussed confuses me. If someone is very low risk for prostate Ca in their 40s and make up less than 10% of prostate cancer diagnoses when followed up why would you continue to screen them in 5-7 years or again at all?

 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.

I found this interestingly nonspecific which I guess is the point. The risks of overdiagosis do need to be stressed more than with younger patients. Also the benefit is unclear as patients age beyond 70.

“Dr. Patrick Walsh, the noted Johns Hopkins urologist and forceful advocate for prostate cancer screening, famously (and humorously) said that he would not do a PSA test on a man older than 75 unless he was brought to the office by both his parents.”

 

 Media discussion:

The media uptake of the consensus statement has been pretty impressive. All the major networks picking up the story and print media have also followed suit. Unfortunately the stories have been one sided and this may be a “necessary evil” but the reality is this document will be seen as the prostate cancer experts giving their opinion on screening even if that is not the stated intention.

“ONE of the world’s greatest medical debates has come to an end with experts  agreeing that men should start testing for prostate cancer in their 40s.”

Read more:  http://www.news.com.au/lifestyle/health-fitness/prostate-cancer-test-should-be-taken-by-men-in-their-40s/story-fneuzlbd-1226692750214#ixzz2be5K2une

 You tube video of the media response:

http://www.youtube.com/watch?v=a1qUGG1-68g

From some of the comments from the BJUI website:

Associate Professor Ian Haines clearly not convinced of the merits of the document:

“This appears to be a pointless, self-serving, unbalanced, unhelpful piece of ‘propaganda’ 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.”

I am comforted by the comments of Mike Leveridge

“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).”

 A final thought will be left to Minh le Cong who left a comment which I think reflects the thoughts of myself and the other GPs at my peer review:
“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.”