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  1. 1
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    Simon Chapman

    I’m intrigued by your comment Ian that “most oncologists I speak to will not have a PSA themselves.” I recently tried to survey the membership of COSA (the Clinical Oncology Society of Australia) about members’ cancer protective behaviours (including PSA testing) but unfortunately received a disappointing response rate from men, leaving a cloud above this question. This Victorian study shows 45% of male drs aged 49+ have been tested http://www.ncbi.nlm.nih.gov/pubmed/12036219 but a 2006 US study shows 95% of urologists and 78% of non-urologists have been tested there.
    Is this any more than an impression?
    Simon

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  2. 2
    Croakey

    Croakey

    Ian Haines asked me to post this comment on his behalf: “Thank you for the question Simon and for your ongoing and important contributions to the research and discussions about this important topic. My impressions are purely anecdotal and based on conversations within my circle of oncologists. I think it would very interesting to see how many responses you receive, if you put the question again via COSA, and what those responses would be It would also be interesting to compare how many doctors pursue screening for bowel cancer, for which there is high-level evidence for benefit,with whether those same doctors have a PSA for which there is no good evidence.”

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  3. 3
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    Doctor Whom

    The screening for Bowel Cancer is a little bit messier and therefore more complicated than the PSA screening. So a direct comparison is not all that good.

    Much easier for a oncologist or urologist to grab a quick PSA test at work on a whim than to grab a quick FOBT or Colonoscopy.

    Well except I guess if the rates screening were higher for Bowel Cancer.

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  4. 4
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    Gavin Mooney

    Ian Haines’ comment is prefaced by the following: “Much of the discussion around health care reform, whether in Australia or the US, seems to be based upon an assumption that more medicine is better.” Yes – but better for whom?

    As someone who quickly stepped off ‘the PSA roller coaster’, might I suggest some research on EBM and SID (supplier induced demand).

    1. On EBM I hypothesise that urologists will have reduced their PSA testing in the wake of the publication of the results of the two trials in 2009.

    2. On SID I hypothesise that urologoists will not have reduced their PSA testing in the wake of the publication of the results of the two trials in 2009.

    The evidence must be there to test these hypotheses.

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  5. 5
    Croakey

    Croakey

    Hi Gavin, perhaps I should have made my meaning a little more explicit at the start… I meant: a “misplaced” assumption that more medicine is better for the population’s health…Cheers, Melissa

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  6. 6
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    Jon Hunt

    I think that occult blood screening for bowel cancer has been demonstrated to provide some benefit in terms of outcomes.

    This is in comparison to PSA testing. Although I am a doctor I still seem to be able to become recurrently confused by this test. I try to explain to patients the pros and cons of the test but most seem to have already made up their mind before they see me. They still want it. I imagine that they would rather know than not know, yet they could be doing themselves harm by having it. People have their radical prostatectomy and then think they have been “cured”, or they know of someone who has.

    For me, I would rather not have it. And if it has not been shown to have benefit why are we still doing them even if the patient asks for it, because if they ask for it this would likely imply that they do not understand the test, and so how can they give informed consent?

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  7. 7
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    Leo Braun

    Anyone seeking to ascertain the viability of the conditional PSA tests bulk-billing terms ought to peruse 18-01-10 dated attachment received by me on 22-01-10 within the email dispatched from Canberra as a consequence of my complaint emailed to the Minister for Health on 15-11-09. Incredibly though, respondent claimed that she replied to 18-01-10 dated email, supposedly received on the day of her “prompt response”! To find out all about the shocking state of affairs have a look at … http://blogs.crikey.com.au/croakey/2009/09/24/for-another-view-on-prostate-cancer-screening/#comment-830

    182KB PDF D09032641 TRANSCRIPT

    Australian Government
    Department of Health and Ageing
    GPO Box 9848 Canberra ACT
    Tel: (02) 6289 1555
    Fax: (02) 6289 8509

    Mr Leo Braun
    conscientious_citizen@yahoo.com.au

    Dear Mr Leo Braun

    Thank you for your email of 18 January 2010 to the Minister for Health and Ageing, the Hon Nicola Roxon MP, concerning Prostate Specific Antigen (PSA) blood testing prostate cancer. The Minister has asked me to reply on her behalf.

    The Pathology Services Table (PST) of the Medicare benefits Schedule lists the pathology tests for which Medicare benefits are available, their Schedule fees and conditions for use. The Government is advised on the composition of the PST by the Pathology Services Table Committee (PSTC) which includes experts in pathology from private industry and public hospital practice. The Committee keeps the Table under review to ensure that the services, fees and conditions for use are appropriate, and consults with professional and other expert groups on these issues.

    In order to encourage pathology providers to bulk bill, from 1 November 2009, the government introduced new bulk billing incentives for all pathology episodes at a cost of $348 million over four years. This will encourage pathologists to maintain their current high rate of bulk billing.

    Under the Medicare Benefits Schedule, medical practitioners, including pathologists, are free to set their own value on the services they provide. While the government is responsible for setting the Schedule fee on which Medicare benefits are based, there is nothing to prevent pathologists or any other medical practitioner setting fees that exceed those in the Schedule. The government encourages bulk billing, but it is at the provider’s discretion whether or not to bulk bill.

    The government encourages medical service providers to discuss with patients the likely costs of all their treatment. If you are dissatisfied with the billing arrangements from your current pathology provider, you may wish to consider asking your doctor to refer you to a pathology provider that bulk bills. Patients are entitled to chose their own pathology provider, so I hope that you can feel comfortable asking your doctor to refer you to a provider who better meets your needs.

    From the information provided in your email it is not possible to determine which item numbers your tests were billed under. However, I am able to provide information on items which are applicable to the tests you had. There are four items on the Medicare Benefits Schedule for the quantitation of PSA — items 66655, 66656, 66659 and 66660.

    Item 66655 is the standard item providing a rebate for a PSA test if there is no previous diagnosis of prostatic disease and is restricted to being claimed once in a twelve month period. Item 66659 is a follow up item to 66655 if a PSA result lies in the equivocal range of the particular method of assay used to determine the level. The range applied is dependent on the method used and the age of the patient, since PSA levels will vary with these factors.

    Items 66659 and 66660 are more in-depth tests that can be used when an initial PSA result is not conclusive. Item 66659 can be claimed once in a 12 month period and item 66660 can be claimed four times, it is used when initial test returns a result well outside the normal range.

    Item 66656 is the test used in the monitoring of previously diagnosed prostatic disease and there is no restriction on the number of items this test can be claimed for a Medicare rebate in a 12 month period providing that the treating practitioner deems it to be appropriate.

    It is not clear from your letter whether you have in fact been diagnosed with prostatic disease. If that is the case, then you should have been billed for either item 66656 or item 66660. In order for the pathology provider to bill the correct item number, they need to be provided with sufficient information in the clinical notes on the request form. You may like to discuss this with your requesting practitioner and ask them to make it clear to the pathology provider that you have previously been diagnosed with prostatic disease (if that is the case). You may then wish to discuss with the pathology provider having your account amended to reflect the correct item number.

    In clarifying the information provided by QML in their May 2009 newsletter on their website, prior to 1 May 2009 three items were available for PSA testing on the PST of the Medicare Benefits Schedule — items 66655, 66656 and 66659. Item 66659 provided for one test of PSA fractions in a 12 months period, if a previous PSA test was equivocal.

    The changes introduced on 1 May 2009 clarified the conditions that define an equivocal result. Item 66659 now provides for follow-up testing of PSA fractions when the initial result lies within a certain range. The range applied is dependent on the method used and the age of the patient, since PSA levels will vary with these factors. In addition, item 66660 was introduced to allow for up to four tests of PSA fractions within a 12 months period if each follows a total PSA result that is in a higher range but still not definitive.

    For your information, Australia does not have an organised prostate cancer screening program. In determining whether there is sufficient evidence to establish an organised screening program, the Government has developed a Population Based Screening Framework, based on the World Health Organization (WHO) screening principles, to provide guidance for decision makers when considering potential population based screening programs in Australia. Currently, there is limited evidence to indicate improved health outcomes or a mortality decline to benefit from routine prostate cancer testing through a national population based screening program, using either the Prostate Specific Antigen (PSA) test or any other available method.

    There is no generally accepted population screening test for prostate cancer. Research has shown that screening for prostate cancer using existing test options would result in frequent false positive results (a positive result when there is actually no cancer present) leading to unnecessary patient anxiety and treatments that may affect patients’ health, including sexual, urinary and bowel dysfunction. Researchers continue to seek better ways of detecting prostate cancer at an early stage. The decision to undertake a PSA test is a personal choice to be made by men, in consultation with their doctor, who can advice on the risks and benefits of testing in relation to their specific circumstances.

    In the future, it may be advisable for you to contact the provider or discuss the items with your referring practitioner to identify the conditions for Medicare rebates. I assure you that the Government is committed to making high quality and affordable healthcare, available to all Australians. I hope this information has been useful to you.

    Yours sincerely

    A/g Assistant Secretary
    Diagnostic Services Branch
    18 January 2010

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  8. 8
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    Clancy Philippe

    I have immense trust in Ian. he was my wife’s oncologist over the last five years during her battle with breast and ovarian cancer. Ian won our admiration for his professionalism, friendship and consideration for his patients. He became our trusted friend and companion in our fateful battle with cancer. He ensured that my wife (Madeleine) maintained to the utmost her quality of life, despite the odds of beating both genetic breast & ovarian cancer. Thank you Ian.

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