Helen Salisbury: Opportunity costs and the time needed to treat
BMJ 2023; 380 doi: https://doi.org/10.1136/bmj.p168 (Published 24 January 2023) Cite this as: BMJ 2023;380:p168
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Dear Editor,
Helen Salisbury (Opportunity costs and time to treat, BMJ 28 January) is a good writer and has a point. PSA testing for men over a certain age should ideally be done outside General Practice via a screening set-up, as we do for bowel or breast cancer. However, prostate cancer screening has been shown to reduce mortality (1) and has been recommended by a number of bodies including the European Association of Urology (2) and the European Commission (3).
The evidence has shifted in favour of screening because of a number of game changers such as multi-parametric MRI (many men with a positive PSA will not always need biopsies) and the establishment of active surveillance, meaning patients with low-grade cancer will not suffer from overtreatment. There is increasing recognition that early diagnosis is not just about mortality: the more advanced the prostate cancer at diagnosis, the worse the effects of treatment on quality of life.
Prostate Cancer UK (4) supports the right of men to request a PSA test via their GP, as there is no other route. General Practice, as well as A&E departments, would benefit from a reduction in the number of attendances due to urological complications or metastatic spread of prostate cancer.
Personally, I would have not retired from my Consultant post if my prostate cancer had been diagnosed earlier and my prostatectomy had resulted in cure. My prostate cancer, despite being only a Gleason score 7, had already spread beyond the resection margins. When I meet with other prostate cancer patients, I can see how life is much more miserable for those, amongst us, who require further treatment such as salvage radiotherapy or androgen deprivation.
Better health via screening and healthier lifestyles is the best strategy to reduce the NHS workload.
1. Schroder FH, Hugosson J, Roobol MJ, et al. Screening and prostate cancer mortality: results of the European Randomised Study of Screening for Prostate Cancer (ERSPC) at 13 years of follow-up. Lancet 2014;384(9959):2027-35.
2. https://www.europeanurology.com/article/S0302-2838(21)01927-8/fulltext
3. https://ec.europa.eu/commission/presscorner/detail/en/qanda_22_5584
4. https://prostatecanceruk.org/for-health-professionals/guidelines/interim...
Competing interests: No competing interests
Re: Helen Salisbury: Opportunity costs and the time needed to treat
Dear Editor
Helen Salisbury as always brings many useful insights, including Radio 4 giving prominence to an opinion re PSA testing contrary to current advice in the UK and USA. What I would like to debate though are guidelines and the risk that they may deskill and demotivate GPs, as well as being impossible to read and digest.
Take CSOM (chronic supportive otitis media) where the guidelines say GPs not to treat but refer where after a wait of many months first line treatment is likely to be topical or systemic antibiotics. NICE also recommends all people with heart failure are referred after an initial examination and biochemistry and where available an echo request. This may mean that as a profession we lose confidence and competence at managing this common condition and after a spell under secondary care people are discharged back to primary care.
My suggestion is that we are allowed to up-skill and for most people (excluding amyloid, primary valvular causes and rare things that one hope would have been shown on the echo) this is one of many things that could and possibly should be looked after in primary care, maybe with advice and guidance. Yes there will be GPs who will say there is no time for this, maybe. May I suggest we move safeguard training to be less frequent, and how many more lives would be saved if education re this replaced annual CPR updates. Many other examples exist - 3 day training for spirometry - so in reality it may not be easily available, fNO testing for asthma diagnosis as examples.
Guidelines seem to work in an ideal environment, not in the world of waiting lists and multimorbidity perhaps?
Competing interests: No competing interests