Prevalence of invasive cancer in a large general practice patient population in New Zealand.

INTRODUCTION The prevalence of cancer in the community is likely to be increasing due to an ageing population, implementation of cancer screening programmes and advances in cancer treatment. AIM To determine the prevalence of primary invasive cancers in a large general practice patient population in New Zealand and to characterise the health-care status of these cancer patients. METHODS Data were sourced from the patient management system of a large general practice (n=11,374 patients) in a medium-sized Waikato town and from the New Zealand Cancer Registry dataset to identify patients diagnosed with cancer between January 2009 and December 2018. RESULTS There were 206 cancer diagnoses in 201 patients; 35 cancers were diagnosed in 1887 Maori patients (1.9%) and 171 in 9487 non-Maori patients (1.8%). The age-standardised prevalence was 3092/100,000 in Maori patients and 1971/100,000 in non-Maori patients. The most prevalent cancers were breast, male genital organ, digestive organ and skin cancers. In May 2019, 81 of 201 (40.8%) patients with cancer were receiving only usual care from their general practitioner, whereas 66 (32.8%) were having their cancer managed in secondary care. Comorbidities were common, including hypertension (38.8%), gastrointestinal disorders (29.9%) and mood disorders (24.4%). DISCUSSION Results suggest that there may be disparities in cancer prevalence between Maori and non-Maori patients, although this needs to be confirmed in other general practices. Furthermore, primary care appears to be responsible for most of the care in this patient cohort and workloads should be planned accordingly, particularly with the high incidence of comorbidities.

Rural-Urban Differences in Prostate-Specific Antigen (PSA) Screening and Its Outcomes in New Zealand.

PURPOSE: To examine prostate-specific antigen (PSA) screening patterns and outcomes in rural and urban men in New Zealand. METHODS: Men aged 40+ years were identified from 18 rural and 13 urban general practices across the Midland Cancer Network region. Computerized practice records were cross-referenced with community laboratory data to ascertain the number and level of PSA tests undertaken in 2010 and 3 years prior. For men with an elevated PSA result in 2010, practice records were searched for information on specialist visits, and they were cross-referenced with histology reports regarding biopsy and prostate cancer diagnosis. FINDINGS: The study population included 34,960 men aged 40+ years, of whom 48% were enrolled in rural practices. Men in rural practices were 43% less likely to be screened with a PSA test in 2010, but they were 53% more likely to have an elevated PSA result. The prostate cancer detection rate from all screened men was 6 per 1,000 for rural men compared with 3 per 1,000 for urban men. Rural men were more likely diagnosed with Gleason score 9 tumors and metastatic disease. CONCLUSION: Significant differences were found in PSA screening patterns between rural and urban general practices. Due to lower screening rates, rural men were more likely to be diagnosed with prostate cancer when screened and also seemed to be diagnosed with more advanced disease compared with urban men. Despite ongoing discussions about the benefits and harms of PSA screening, PSA testing as such seems to be under-utilized in New Zealand rural practices.

The patient perspective on a first raised PSA test.

INTRODUCTION: Approximately 350 000 prostate-specific antigen (PSA) tests are undertaken in New Zealand on a quarter of a million men each year. A number of studies have looked at PSA testing done by general practitioners (GPs) and subsequent outcomes. Few have looked at the patient perspective after a raised PSA result. AIM: To explore patient experiences up to and following a raised PSA test. METHODS: Thirty-one general practices within the Midland region were recruited. Community laboratory databases were used to identify all men with a first raised PSA test during 2010. Questionnaires were sent to these men. RESULTS: One hundred and ninety-four (63%) eligible responses were received from 307 eligible men delivered questionnaires. For 54% of men this was their first PSA test. Most men (66%) identified that their PSA test was initiated by their GP. Forty-three percent of men identified having symptoms at the time of their first raised PSA test. A digital rectal examination (DRE) was performed on 73% of men at the time of the test. Fifty-eight percent of men were referred to see a specialist. Maori men were less likely to be referred after a raised PSA. Of all men referred, 61% received a biopsy. DISCUSSION: PSA testing is predominantly initiated by GPs. We found the care pathway is variable for men after an elevated PSA result. Standardisation of the pathway prior to and post diagnosis would assist patients in knowing what to expect and would aid in GP management of men being investigated for prostate cancer.

Prostate-specific antigen (PSA) screening and follow-up investigations in Maori and non-Maori men in New Zealand.

BACKGROUND: Maori men in New Zealand have higher mortality from prostate cancer, despite having lower incidence rates. The objective of this study was to examine patterns of screening for prostate cancer in primary care and follow-up investigations after an elevated prostate-specific antigen (PSA) result in Maori and non-Maori men in order to help explain the observed differences in incidence and mortality. METHODS: Men aged 40+ years were identified from 31 general practices across the Midland Cancer Network region. Computerised practice records were cross-referenced with laboratory data to determine the number and value of PSA tests undertaken between January 2007 and December 2010. Screening rates were calculated for the year 2010 by age, ethnicity, and practice. For men with an elevated PSA result information on specialist referrals and biopsy was extracted from practice records. Practice characteristics were assessed with respect to screening rates for Maori and non-Maori men. RESULTS: The final study population included 34,960 men aged 40+ years; 14% were Maori. Maori men were less likely to be screened in 2010 compared with non-Maori men (Mantel Haenszel (M-H) age-adjusted risk ratio (RR), 0.52 [95% CI, 0.48, 0.56]). When screened, Maori men were more than twice as likely to have an elevated PSA result compared with non-Maori men (M-H age-adjusted RR, 2.16 [95% CI, 1.42, 3.31]). There were no significant differences between Maori and non-Maori men in the rate of follow-up investigations and cancer detection. Maori provider practices showed equal screening rates for Maori and non-Maori men, but they were also the practices with the lowest overall screening rates. CONCLUSIONS: Maori men were half as likely to be screened compared to non-Maori men. This probably explains the lower reported incidence of prostate cancer for Maori men. Practice characteristics had a major influence on screening rates. Large variation in screening behaviour among practices and differences in follow-up investigations for men with an elevated PSA result seems to reflect the uncertainty among GPs regarding PSA screening and management.

The costs of identifying undiagnosed prostate cancer in asymptomatic men in New Zealand general practice.

BACKGROUND: Screening for prostate cancer (PCa) using the prostate-specific antigen (PSA) test is widespread in New Zealand. Aim. This study estimates the costs of identifying a new case of PCa by screening asymptomatic men. METHODS: Men aged 40+, who had PSA tests in 31 general practices in the Midland Cancer Network region during 2010, were identified. Asymptomatic men without a history of PCa were eligible for this study. A decision tree was constructed to estimate the screening costs. We assumed GPs spent 3 minutes of the initial consultation on informed consent of PCa screening. RESULTS: About 70.7% of the estimated costs were incurred in general practice. The screening costs per cancer detected were NZ$10 777 (€5820; £4817). The estimated costs for men aged 60-69 were NZ$6268 compared to NZ$24 290 for men aged 40-49, NZ$30 022 for 50-59 and NZ$10 957 for those aged 70+. The costs for Maori were NZ$7685 compared to NZ$11 272 for non-Maori. The costs for men without PSA testing history in 2007-09 were NZ$8887 compared to NZ$13 870 if the men had PSA tests in 2007-09. If we assumed a PSA test involved a full 15-minute general practice consultation, the estimated costs increased to NZ$26 877 per PCa identified. CONCLUSIONS: Screening of asymptomatic men for PCa is widely practiced. Most of the costs of screening were incurred in general practice. Calls for men to receive increased information on the harms and benefits of screening will substantially increase the costs. The current costs could be reduced by better targeting of screening.

PSA testing in general practice.

INTRODUCTION: In New Zealand, prostate-specific antigen (PSA) testing has increased significantly (275 000 tests/year). Controversy exists around PSA testing as part of an unorganised screening programme. AIM: To look at the use of PSA testing in a sample of general practices and investigate the reasons GPs undertake PSA testing. METHODS: Five Waikato general practices investigated looking at PSA laboratory tests of men ≥40 years in 2010 compared against GP notes. Testing rates, reasons for testing, histology and referral/s were examined for different age groups. A questionnaire was sent to the GPs to determine their views on PSA testing. RESULTS: One in four men aged 40+ years had a PSA test in 2010. Of these men, 71% were asymptomatic. More than half of men tested aged 70+ years were asymptomatic. Ten percent of all PSA tests were elevated. Twenty-one of 23 prostate cancers were diagnosed following an elevated PSA test: more than 80% of these men had histories of prostate pathology or lower urinary tract symptoms. The questionnaire confirmed that GPs believe in the benefits of PSA screening and it also showed they had difficulty in providing patients with information about pros and cons of PSA testing. DISCUSSION: All GPs in this study tested asymptomatic men. GPs in this study value PSA screening and believe that it reduces mortality rates. However, although PSA tests were most frequently done on asymptomatic patients, the majority of patients subsequently diagnosed with prostate cancer had been tested because of symptoms or had previous prostate problems.