FINAL REPORT: The Midlands Prostate Cancer Study: Understanding the Pathways of Care for Men with Localised Prostate Cancer in New Zealand

Full text

FINAL REPORT
THE MIDLANDS PROSTATE CANCER STUDY:
UNDERSTANDING THE PATHWAYS OF CARE FOR MEN
WITH LOCALISED PROSTATE CANCER
Health Research Council Reference: 11/082
Auckland UniServices Limited
A wholly owned company of
The University of Auckland
Prepared for:
Health Research Council
And
Ministry of Health
Prepared by:
Professor Ross Lawrenson
Dr Charis Brown
Dr Zuzana Obertova
Ms Chunhuan Lao
Dr Helen Conaglen
Date: February 2014

2
Reports from Auckland UniServices Limited should only be used for the purposes for which they were
commissioned. If it is proposed to use a report prepared by Auckland UniServices Limited for a different
purpose or in a different context from that intended at the time of commissioning the work, then UniServices
should be consulted to verify whether the report is being correctly interpreted. In particular it is requested that,
where quoted, conclusions given in UniServices reports should be stated in full.

3
Tēnā rā koutou, e te iwi nui tonu, me te whaikorōria tonu i te Atua Kaha Rawa. Kia
tau, tonu, ōna manaakitanga maha ki runga i a Kiingi Tūheitia, me tona Whare Ariki
nui tonu!
Kua tangihia, kēngia, ngā mate o te wā! No reira, ka waihongia rātou ki a rātou!
Tātou, kē, o te ao morehu, ki a tātou!
Ka kitea, i raro nei, he kaupapa whakahirahira ka pa ki te kaupapa rangahaua ngā
āhuatanga e pā ana ki te oranga, kore oranga rānei, o te taha-a-tinana o te tāne, e
mōhiotia ana ko te repe tātea; i runga anō i te mōhiotanga, ko te mate pukupuku o
te repe tātea, o te tāne, tētehi o ngā momo mate pukupuku e peehi kino ana i a
tātou tāne Māori.
Ma te aata mātai, aata whakawetewete i aua āhuatanga, ka taea, pea, te kitenga i te
ara haerenga whakamua; hei oranga ,ake, mo a tātou tāne; ara, me pēwhea te tū
‘Kia hiwa rā...’ o ngā tāne, kia kaua rātou e peehi kinohia e taua momo mate.
Ma te Runga Rawa e tiaki, e manaaki tonu, i a tātou katoa;
Pai Marire!

4
MESSAGE FROM THE PRINCIPAL INVESTIGATOR
This report is the synthesis of 3 years work from a multi-disiplinary team of clinicians
and researchers. We describe the pathways that men go through to a diagnosis and
subsequent treatment for prostate cancer. This has led us to make a number of
recommendations, which we hope will improve the journey for men and their families.
I would like to thank all those who have helped us in our endeavors – including
Auckland UniServices Ltd, our project partners the Midland Cancer Network, our
clinical colleagues, the general practices that participated in the PSA study, the
patients and partners who shared their personal experiences, Pathlab, Waikato, Bay of
Plenty and Lakes district health boards, members of our governance and advisory
groups and of course the Ministry of Health and Health Research Council for their
support.
We hope you find this report informative.
Sincerely,
Ross Lawrenson

5
EXECUTIVE SUMMARY
Background
The Health Research Council of New Zealand along
with the Ministry of Health issued a request for
proposals (RFP) during 2010 to increase the
evidence-base about the current prostate cancer
pathway from diagnosis to outcomes. The specific
objectives of the RFP included:
 The pathways of care following an abnormal
PSA test
 The costs of care to the individuals and the
community
 The spectrum of complications arising from
diagnosis and treatment
 The implications for equitable access for Maori
men to care
The following report is the response to this RFP and
covers the full pathway of care for men diagnosed
with localised prostate cancer.
Introduction
For New Zealand men, prostate cancer is the most
commonly registered cancer. Māori men are less
likely to be diagnosed with prostate cancer, but
when diagnosed they are twice as likely to die.
Prostate specific antigen (PSA) testing is commonly
carried out in New Zealand with approximately
80% of testing done on asymptomatic men and can
be described as opportunistic screening. Little is
known about what occurs once an asymptomatic
man has an abnormal PSA result. Treatment
options in New Zealand vary and differences in
outcomes of screening have not been evaluated in
the local setting. There is evidence that treatment
for prostate cancer can commonly cause
moderate-to-substantial harms. We have less
reliable information about the wider complications,
including social and psychological impact. We also
do not have a good understanding of the financial
costs associated with diagnosis and treatment of
prostate cancer in New Zealand and who pays.
Our aim was to examine the pathways of care
following an abnormal PSA test for prostate cancer,
with a focus on differences within the pathway for
Māori vs. non-Māori and rural vs. urban men.
Methods
We developed a four phase approach:
For the first phase, prostate cancer registrations
were obtained from the New Zealand Cancer
Registry (NZCR) for the period 1996-2010 These
data were linked to the national mortality data.
Temporal trends in incidence and survival were
analysed to identify differences between age
groups, Maori and non-Maori and between the
four Cancer Networks.
Phase two explored PSA testing in general practice.
GP clinics in the Midland region were recruited.
Access to laboratory data was gained and each
practice Medtech system was searched. Patient
surveys were undertaken to identify reasons why
men believed they received their initial PSA test.
We also investigated the health care costs involved
in the primary to secondary diagnosis process.
Phase three focused on the management of
localised prostate cancer patients within the
Midland region. All Māori men (n=150) from the
Midland region diagnosed with prostate cancer
during 2007-2010 were identified from the NZCR
and age matched to three NZ European men
(n=450). We recreated the cancer care pathways of
the 600 patients from original referral to post-
treatment outcomes. A decision tree for the
management of prostate cancer was developed.
Finally, phase four examined the impact of prostate
cancer diagnosis and treatment on patients and
their partners using structured questionnaires to
measure key outcomes. Men were recruited from
the phase three cohort.
Results
Men with localised prostate cancer have a good
prognosis, with a high proportion surviving more
than 10 years without treatment. Men in the MCN

6
were more likely to die of prostate cancer than
men in any of the other three CNs. Māori men
were more likely to die with and of prostate cancer
compared with non-Māori men. This is despite the
fact that survival improved in both Māori and non-
Māori men. The survival gap between the groups
has not reduced with time.
9,344/35,734 men were PSA tested during 2010.
85% of the testing was screening. PSA testing varies
considerably between general practices (from 7%
to 41%). Māori men and men in rural areas are less
likely to be PSA tested. Surprisingly much of the
testing in men aged 70 years plus was
asymptomatic screening. About 12% of PSA tests
were deemed to be elevated, although only 2.1%
were identified from screening. 43% of men with
elevated PSA levels were referred to a specialist.
When referred 65% of men were biopsied with
55% having a positive result. When tested and
biopsied, Māori men are more likely to have a
positive result.
Prostate cancer patients in the Midland region
were primarily diagnosed with localised prostate
cancer (76.1%). 11.8% with locally spread prostate
cancer and 12.1% with metastatic prostate cancer.
Māori men were significantly more likely to have
metastatic cancer at the time of diagnosis than
non-Māori. Treatment options in men with
localised cancer varied and were influenced by age,
risk score and the presence of co-morbidities. Non-
Maori men more likely to have surgical
intervention or low-dose rate brachytherapy,
Maori men were more likely to have external beam
radiotherapy.
106 men and 54 partners were surveyed to
understand treatment choices and the impact of
living with a prostate cancer diagnosis and
treatment. The main factor identified by men as
influencing their treatment choice was the doctor’s
recommendation. 73% of men thought they had
good treatment options before making a decision
about what treatment to undergo. Overall men
expressed a good rate of return to normal life 3-6
years post diagnosis. However, men still had
information and supportive care needs post-
treatment. Partners also identified a high level of
on-going stress.
Recommendations
This study makes recommendations to inform and
help improve the pathways of care for men with
prostate cancer. There are clear recommendations
for GPs regarding PSA testing, referral to specialist
and the need to monitor men after an abnormal
PSA test. Recommendations also cover improving
the recording of cancers and add to the
management of men after diagnosis and
treatment.

7
Contents
1. BACKGROUND ........................................................................................................................................ 10
2. STRUCTURE ............................................................................................................................................ 12
3. AN INTRODUCTION TO PROSTATE CANCER ........................................................................................... 14
4. PUTTING THE MIDLAND PROJECT IN CONTEXT: UNDERSTANDING PROSTATE CANCER TRENDS
NATIONALLY, REGIONALLY AND BY ETHNICITY ...................................................................................... 17
1. PROSTATE-SPECIFIC ANTIGEN TESTING IN GENERAL PRACTICE: PATHWAYS OF CARE FOLLOWING A
PSA TEST ................................................................................................................................................ 28
6. MANAGEMENT OF LOCALISED PROSTATE CANCER IN SECONDARY CARE: TREATMENT CHOICES,
OUTCOMES AND COMPLICATIONS FOLLOWING DIAGNOSIS ................................................................ 39
7. LIVING WITH PROSTATE CANCER: ASSESSING THE SPECTRUM OF COSTS AND COMPLICATIONS ALONG
THE PATHWAY ........................................................................................................................................ 47
8. REPORT RECOMMENDATIONS ............................................................................................................... 65
9. APPENDICES ........................................................................................................................................... 68
10. ACKNOWLEDGEMENTS .......................................................................................................................... 93

List of Figures
Figure 3-1: Incidence-new cases of prostate cancer in
New Zealand. ................................................. 14
Figure 3-2: Number of new cases of prostate cancer in
New Zealand by age (2008). .......................... 14
Figure 3-3: Number of deaths from prostate cancer in
New Zealand by age (2008). .......................... 14
Figure 3-4: Mortality rate of prostate cancer in New
Zealand 1970-2008. ....................................... 15
Figure 4-1: Age-standardised (WHO men 40+ years)
incidence rates of prostate cancer for New
Zealand, Australia, USA, Canada, UK, Sweden
and Germany [3]. ........................................... 17
Figure 4-2: Age-standardised (WHO men 40+ years)
prostate cancer mortality rates for New
Zealand, Australia, USA, Canada, UK, Sweden
and Germany [3]. ........................................... 17
Figure 4-3: Annual age-standardised (WHO) prostate
cancer incidence and mortality rates in New
Zealand men [3]. ............................................ 17
Figure 4-4: Five-year prevalence of common cancer in
New Zealand [3]. ............................................ 18
Figure 4-5: Age-specific incidence rates of prostate
cancer in our cohort. ..................................... 21
Figure 4-6: Age-standardised (NZ men aged 40+ years
from 2001 Census) incidence rates total and
by ethnicity. ................................................... 22
Figure 4-7: Age-standardised (NZ men aged 40+ years
from 2001 Census) incidence rates by ethnicity
and age group. ............................................... 22
Figure 4-8: Age-standardised (NZ men aged 40+ years
from 2001 Census) incidence rates by Cancer
Network. ........................................................ 22
Figure 4-9: Number of PSA tests per 100 men aged 40+
years by Cancer Network [21]. ...................... 23
Figure 4-10: Cancer-specific survival by years of
diagnosis and Cancer Network. ..................... 24
Figure 4-11: Cancer-specific survival by years of
diagnosis and ethnicity. ................................. 24
Figure 5-1: Response rate to questionnaire by practice.
....................................................................... 30
Figure 5-2: Proportion of testing/screening by practice
during 2010. .................................................. 31
Figure 5-3: Proportion of testing/screening during 2010
by age and ethnicity. ..................................... 31
Figure 5-4: Proportion of elevated PSA during 2010 from
testing/screening by age group..................... 32
Figure 5-5: Previous PSA tests (2007-2009) in screened
men. .............................................................. 32
Figure 5-6: Proportion of overall PSA testing and
screening by settlement size. ........................ 32
Figure 5-7: Proportion of self-reported patient DREs at
time of raised PSA test during 2010. ............. 35
Figure 6-1: Stage at diagnosis by ethnicity. .................. 40
Figure 6-2: Stage at diagnosis by age and ethnicity. .... 41
Figure 6-3: Treatment type by age group. ................... 41
Figure 6-4: Treatment type by ethnicity. ...................... 42
Figure 6-5: Treatment type by DHB. ............................. 42
Figure 6-6: Charlson score by treatment type. ............. 43
Figure 6-7: PSA level by treatment type. ...................... 43
Figure 6-8: Gleason score by treatment type. ............. 43
Figure 7-1: Number of men interviewed by age group
and ethnicity.................................................. 49
Figure 7-2: Relationship status and duration. .............. 49
Figure 7-3: Partner's age group. ................................... 49
Figure 7-4: Original diagnosis and first treatment by
year (number). .............................................. 50
Figure 7-5: Proportion of self-reported treatment type
by ethnicity. ................................................... 51
Figure 7-6: Couples’ ethnicity. ..................................... 55
Figure 7-7: Original diagnosis and first treatment by
year. ............................................................... 56
Figure 9-1: Pathway of screening for prostate cancer in
New Zealand. ................................................. 71
Figure 9-2: Proportion of the costs of each type of
medical resources in total cost. .................... 72
Figure 9-3: Treatment pathways for men with localised
prostate cancer. ............................................ 75

List of Tables
Table 3-1: Incidence-new cases of prostate cancer in
New Zealand. ................................................. 14
Table 4-1: List of DHBs by Cancer Network. ................. 20
Table 5-1: Age-specific PSA ranges recommended by
Pathlab ........................................................... 28
Table 5-2: Median PSA level at referral (and non-
referral) during 2010. .................................... 33
Table 5-3: Referral rates, biopsy rates and positive
biopsy rates. .................................................. 33
Table 7-1: Māori men stage 1 and 2 recruitment. ........ 48
Table 9-1: Patient characteristics by Cancer Network
(CN). ............................................................... 68
Table 9-2: Patient characteristics by ethnicity. ............. 68
Table 9-3: Patient characteristics by age group. ........... 69
Table 9-4: Kaplan-Meier all-cause and cancer-specific
survival rates for men diagnosed between
1996 and 2010 by Cancer Network and
ethnicity. ........................................................ 69
Table 9-5: Hazard ratios for all-cause and cancer-specific
survival in men diagnosed with prostate
cancer between 1996 and 2010 by Cancer
Network and ethnicity. .................................. 70
Table 9-6: The unit costs of medical resources. ............ 73
Table 9-7: Quantity of medical resources for prostate
cancer screening. ........................................... 73
Table 9-8: Costs per prostate cancer identified. ........... 74
Table 9-9: Factors influencing men’s treatment choice.
....................................................................... 76
Table 9-10: Patient recall of treatment options
discussed. ...................................................... 77
Table 9-11: Treatment participants reported
undergoing..................................................... 77
Table 9-12: EQ-5D ......................................................... 78
Table 9-13: EORTC-C30 Quality of Life .......................... 78
Table 9-14: EORTC-PR25 ............................................... 79
Table 9-15: HADS and Stress Scales .............................. 79
Table 9-16: Cases identified using HADS and Stress
Scales ............................................................. 79
Table 9-17: Supportive Care Needs Survey – raw scores
....................................................................... 79
Table 9-18: Supportive Care Needs Survey –
standardised scores for comparison with SCNS
dataset for 70+ yr old CaP patients 5-9 months
post-diagnosis ................................................ 80
Table 9-19: Supportive Care Needs Survey –
standardised scores for comparison with SCNS
dataset for long term CaP survivors .............. 80
Table 9-20: Supportive Care Needs Survey – Participants
reporting at least ‘some need’ by domain .... 80
Table 9-21: Miscellaneous sexual activity questions .... 80
Table 9-22: Sexual Health Inventory for Men or
International Index of Erectile Function-Short
Form .............................................................. 81
Table 9-23: Factors influencing choice for patients and
their partners ................................................ 82
Table 9-24: EQ-5D –patients only ................................. 82
Table 9-25: EORTC-C30 as completed by patients and
partners ......................................................... 83
Table 9-26: EORTC-PR25 as completed by patients and
partners ......................................................... 83
Table 9-27: HADS and Stress Scales for patients and
partners^ ....................................................... 84
Table 9-28: Cases identified using HADS and Stress
Scales ............................................................. 84
Table 9-29: Dyadic Adjustment Scale-Short Form ........ 84
Table 9-30: Miller Social Intimacy Scale couples
compared with reference groups .................. 85
Table 9-31: Supportive Care Needs Survey – raw scores
....................................................................... 86
Table 9-32: Supportive Care Needs Survey –
standardised scores for comparison with SCNS
dataset for 70+ yr old CaP patients 5-9 months
post-diagnosis ............................................... 86
Table 9-33: Supportive Care Needs Survey –
standardised scores for comparison with SCNS
dataset for long term CaP survivors .............. 86
Table 9-34: Supportive Care Needs Survey – Participants
reporting at least ‘some need’ by domain .... 86
Table 9-35: Supportive Care Needs Survey-Partner &
Caregiver – raw scores .................................. 86
Table 9-36: Supportive Care Needs Survey-Partner &
Caregiver – Participants reporting at least
‘some need’ by domain ................................. 87
Table 9-37: Miscellaneous queries re sexual activity -
patients ......................................................... 87
Table 9-38: Sexual Health Inventory for Men [SHIM] or
International Index of Erectile Function-Short
Form [IIEF-SF] ................................................ 88
Table 9-39: Miscellaneous queries re sexual activity –
partners. ........................................................ 88
Table 9-40: Female Sexual Function Inventory-Short
Form .............................................................. 88
Table 9-41: Correlations between male and female
sexual function scales .................................... 88

10
1. BACKGROUND
This study was commissioned by the Ministry of
Health and the Health Research Council as a
partnership project. Cancer Control New Zealand
has a clear strategy to:
 Reduce the mortality from cancer
 Reduce the impact of cancer
 Reduce inequalities in access to cancer
services due to ethnicity, economic status
and place of domicile
 Evaluate how effectively new initiatives
have been implemented.
Cancer Research Partnership issued a Request for
Proposals (RFP) in 2010 to inform the evidence
base of patterns of care and reasons for care within
prostate cancer. The purpose of the research was
to provide a description of the types of care
received by men and to demonstrate the equity
issues, costs and complications arising from this
care. The RFP noted that costs of care were not to
be limited to financial costs; social, economic,
psychological and physical costs should all be
considered. The RFP indicated that the research
should also provide details of the proportion of
men who are likely to undergo biopsy after a
prostate-specific antigen (PSA) test. Other areas to
be considered included:
 The pathways of care following an
abnormal PSA test
 The costs of care to individuals and the
community
 The spectrum of complications arising from
diagnosis and treatment
 The implications for equitable access to
care for Māori and Pacific men
A requirement was that the proposed research
should also aim to show at an individual level the
consequences, risk of complications such as
incontinence and erectile dysfunction and the
associated cost and effect on quality of life.
A major aim was that the research should inform
advice and subsequent care provided by health
professionals, and to improve health outcomes and
equity for New Zealand men diagnosed with
prostate cancer.
It was indicated that the identification and
engagement of key stakeholders was essential. The
overall research process was intended to inform
key stakeholders, including the Ministry of Health,
to increase sector buy-in to the initiative and
eventually to allow groups to better prioritise
issues relating to prostate cancer within their
sector.
The University of Auckland (UniServices) responded
to the RFP. The team was principally based in the
Midland Cancer Region, made up of the Waikato,
Lakes and Bay of Plenty District Health Boards
(DHBs). This cancer region has the largest
proportion of Māori men in New Zealand and so
was well placed to examine the issues of equity of
access to cancer care for Māori. The region also
includes a substantial rural population, allowing
research into the influence of geography on cancer
care. The project team included two urologists, a
radiation oncologist, a general practitioner (GP), an
expert on screening and a Māori public health
physician, as well as a statistician, health
economists and social researchers.
To help guide the project we brought together an
academic advisory board of researchers and
stakeholders as a reference body for the different
phases of our research. We also developed a
consumer advisory group with representatives
from Waikato/BOP Cancer Society, New Zealand
Prostate Cancer Foundation, the Midland Cancer
Network, District Health Boards and survivors of
prostate cancer. Finally, we were fortunate in
having easy access to the Waikato DHB Te Puna
Oranga and Midland Cancer Network Māori
advisory group, Hei Pa Harakeke, for guidance on
our research with Māori men in our region.

Although the project had a large scope we have
limits; however, we are fortunate that we have
been able to attract further funding to look at
related topics.
The Waikato Medical Foundation funded a pilot
study of PSA testing in general practice which
helped inform the design of our main study.
The Ministry of Health funded support for a health
economic evaluation of our findings through a PhD
scholarship.
We have applied to the University of Auckland for
additional scholarships using funding from the Sara
Fitzgibbons bequest to look at a study of bone
health in men with prostate cancer.
Finally, we have been successful in an application
to Janssen-Cilag Pharmaceuticals for funding to
look at the use of anti-androgen therapy for men
with metastatic prostate cancer.
The study team has already engaged with a wide
group of stakeholders. Two of the investigators
(Professor Lawrenson and Dr Scott) have
participated in the Ministry of Health Prostate
Cancer Taskforce. We have made presentations to
the Urological Society of Australia and New Zealand
(USANZ), the Royal New Zealand College of General
Practitioners, the UK Royal College of General
Practitioners, the New Zealand Rural General
Practice Network, the Midland Health Network, the
Midland Cancer Network, the Prostate Cancer
Foundation and the Prostate Cancer World
Congress. All peer-reviewed outputs have been
noted in the publication list at the end of this
report. We will continue to disseminate findings
and information to the wider community to help
inform men and their families about prostate
cancer.

2. STRUCTURE
This project was developed with the assistance of
multiple organisations. Project partners were the
University of Auckland and the Midlands Cancer
Network. We worked with various external and
internal groups to assist in our understanding,
through advising and guiding our research process.
External groups included:
 The Waikato District Health Board Iwi Māori
Council
 The Waikato District Health Board Kaumatua
Kaunihera
 The Waikato District Health Board and Midland
Cancer Network Maori Cancer Advisory Group:
Hei Pa Harakeke
 Academic peer reviewers
The identification and engagement of key
stakeholders was seen as essential for the research
project. We therefore set up three key advisory
groups. The first was an Academic Steering Group
(ASG) that included clinical academics dealing day
to day with the issues of men with prostate cancer.
The ASG included a general practitioner (GP),
urologist, radiation oncologist and expert nurses.
The group also included key academics. The ASG
provided academic and clinical governance and
assured the quality of the Midlands Prostate
Cancer research project. The purpose of this group
was to provide expert academic advice and clinical
support to the researchers, ensuring that any risks
identified were assessed and managed.
The second advisory group was the Community
Advisory Group (CAG), which included lay
representatives from the Prostate Foundation, the
Cancer Society, the Midland Cancer Network
(MCN) and local self-help groups. The CAG met on
a regular basis to discuss the implications of
findings. This group was established to provide a
consumer and community perspective to the
Midlands Prostate Cancer research project. The
purpose of the CAG was to provide advice on
methods of consultation with end users, support
with advice to men (referrals) and input into the
study to ensure that the end user perspective is
heard. The third group was the Māori cancer
advisory group, Hei Pa Harakeke. This was a generic
cancer group formed by the WDHB and MCN to
advise on all aspects of care for Māori patients with
cancer – including men with prostate cancer.
Governance
Academic Steering Group
Dr Leanne Tyrie (Waikato DHB)
Ms Jan Smith (Midland Cancer Network)
Dr Charles DeGroot (Formerly Midland Cancer
Network)
Mr Michael Holmes (Waikato DHB)
Ms Lyn Walker (Waikato DHB)
Dr Nina Scott Ngati Whatua, Waikato (Waikato
DHB)
Associate Professor Peter Gilling (Bay of Plenty
DHB, UOA)
Dr Helen Conaglen (UOA)
Associate Professor John Conaglen (UOA)
Dr Fraser Hodgson (UOA and GP)
Associate Professor Alistair Stewart (UOA)
Associate Professor Paul Rouse (UOA)
Professor Toni Ashton (UOA)
Mr John Woodford (Pathlab)
Dr Barry Smith Te Rarawa, Ngati Kahu (Lakes DHB)
Professor Lynn Fergusson (UOA)
Dr Jim Watson (Caldera Health)
Dr Geraldine Leydon (University of Southampton,
UK)
Mr David Musgrave (Formerly Caldera Health)
Dr George Laking: Te Whakatōhea (Auckland DHB
and UOA)
Dr Richard Edlin (UOA)
Consumer Advisory Group

Mr Graham Harbutt (Formerly Waikato Cancer
Society)
Mr Dene Ainsworth Te Ātiawa (NZ Prostate Cancer
Foundation)
Mr Jack Porima Ngati Hikairoa (Raukura Hauora O
Tainui)
Mr Jeffery Morse (Counsellor)
Mr Rawiri Blundell Ngati Porou ki uawa (Midland
Cancer Network)
Ms Margie Hamilton (Midland Cancer Network)
Dr Nina Scott Ngati Whatua, Waikato (Waikato
DHB)
Mr Tamati Peni Raukawa (Waikato DHB)
Mrs Tiffany Schwass (Waikato DHB)
Mrs Lauren James Ngati Whakaue, Te Arawa,
Tuhoe (Lakes DHB)
Team Members
Professor Ross Lawrenson (University of Auckland
(UOA)) – Principal Investigator
Dr Charis Brown - Project Manager
Dr Fraser Hodgson – Pilot Project/Advisor
Dr Zuzana Obertova - Cancer Epidemiology PhD
Student
Ms Chunhuan Lao - Health Economics PhD Student
Ms Alice Wang - Health and Nutrition PhD Student
Mrs Thilini Alwis - Research Assistant
Mr Tamati Peni – Research Assistant
Mrs Diana Benfell - Data Entry
Dr Helen Conaglen – Researcher
Dr Nina Scott Ngati Whatua, Waikato Equity
Advisor
Clinical Workshop
A clinical workshop was held to gain agreement on
recommendations made from the findings of the
report. Members of this workshop were:
Professor Ross Lawrenson
Mrs Jan Smith
A/Professor Peter Gilling
Mr Michael Holmes
Dr Leanne Tyrie
Dr Nina Scott
Mrs Tiffany Schwass
Dr Helen Conaglen
Dr Charis Brown
Dr Zuzana Obertova
Ms Chunhuan Lao
Ms Alice Wang
Mrs Thilini Alwis

14
3. AN INTRODUCTION TO PROSTATE
CANCER
Prostate cancer is the most common cancer in New
Zealand men. It is almost always due to an
adenocarcinoma developing within the prostate
gland, a small gland found at the base of the
bladder. Prostate cancer is usually a slowly growing
tumour that occurs in old age. Most cancers have
an indolent course during the first 10 to 15 years.
For example, three fair-quality cohort studies show
that most men with prostate-specific antigen
(PSA)-detected, non-palpable, localised prostate
cancer have good health outcomes up to 10 years
after diagnosis [1-3]. In 1997 Johansson showed
that in a population-based cohort of men with
prostate cancer, after 15 years of follow-up, 80% of
men who had initially presented with localised
disease were still alive and survival was unaffected
by whether or not they had received treatment [4].
Further follow-up at 15 to 20 years revealed a
substantial decrease in cumulative progression-free
survival [5]. However, it is also recognised that
prostate cancer can occur in middle-aged men in
their 50s and 60s and even occasionally in men in
their 40s. While most cases are slow-growing,
some men present with aggressive tumours, which
seem to progress more rapidly and are more likely
to metastasise.
In New Zealand in 2008, 2,939 men were
diagnosed with prostate cancer, corresponding to a
rate of 93.4 per 100,000. The age-standardised
incidence of prostate cancer increased
substantially with the introduction of PSA testing in
the mid-1990s.
There were 670 deaths due to prostate cancer in
2008, with an age-adjusted incidence rate of 16.6
per 100,000. This is similar to the mortality rate in
1970. Most men are diagnosed with cancer in their
60s and 70s. However, most deaths occur in men
aged 75 years and older.
We know from international literature that there is
a higher incidence rate of prostate cancer in urban
men. This finding suggests that rural men are less
likely to be screened and hence less likely to be
subsequently diagnosed with prostate cancer [6].
Table 3-1: Incidence-new cases of prostate cancer in New Zealand.
Table 3-2:
Table 3-3:
Figure 3-1: Incidence-new cases of prostate cancer in New Zealand.
Figure 3-2: Number of new cases of prostate cancer in New
Zealand by age (2008).
Figure 3-3: Number of deaths from prostate cancer in New
Zealand by age (2008).

15
Although mortality patterns tended to be
heterogeneous, there is some evidence that rural
residents with prostate cancer experience higher
death rates. For Māori men, while their prostate
cancer incidence rate was lower than for the
overall male population in 2008 (74.9 per 100,000),
their mortality rate due to prostate cancer was
higher (32.9 per 100,000). For Pacific men, the
prostate cancer incidence (98.5 per 100,000) and
mortality (23.2 per 100,000) rates in 2008 were
similar to the rates for all men.
Diagnosis and treatment of prostate cancer
Prostate cancer is generally diagnosed either after
presentation to a general practitioner with
symptoms or following screening for prostate
cancer. Men that present with symptoms tend to
have more advanced disease then those identified
through screening. Indeed, some men present
with metastatic disease, affecting other organs.
Typically, asymptomatic men who have been
diagnosed with prostate cancer will have an early
stage tumour confined to the prostate gland. In
these cases the options for treatment include
radical prostatectomy, radiotherapy (focussed
beam or brachytherapy) or active surveillance. A
randomised controlled trial of radical
prostatectomy versus watchful waiting in men
identified from a number of sources including
screening found that during a median follow-up
period of 8.2 years, fewer men in the radical
prostatectomy group than in the watchful waiting
group died of prostate cancer (30 vs. 50, P=0.01)
[7]. The benefit was mostly seen in men aged 65
years and under, for whom the outcomes of
watchful waiting in this study were worse than
those seen with similar management in the older
patients. There is little convincing evidence that
brachytherapy or focussed beam radiotherapy
have different survival outcomes than
prostatectomy. There is evidence that treatment
for prostate cancer can cause moderate-to-
substantial harms, such as erectile dysfunction,
urinary incontinence, bowel dysfunction and, on
occasion, death. A study of long-term outcomes
from radical prostatectomy, external beam
radiation therapy and brachytherapy, around 20%
of men experienced urinary incontinence, 60% had
erectile dysfunction and 10-15% had problems with
bowel function after 2 years. Urinary incontinence
was more common after radical prostatectomy,
bowel dysfunction was more common after
radiation therapy and all three treatment
modalities profoundly affected sexual function [8].
These harms are important because many men
with prostate cancer who are treated would never
have developed symptoms related to the cancer
during their lifetime.
Treatment options in New Zealand vary between
District Health Boards (DHBs), and differences in
outcomes of the various options have not been
evaluated in the local setting.
The Select Committee report of 2011 [9]
recommended that effort should be made to:
• Decrease the risk of harm and improve the
current unorganised prostate cancer screening
pathway in New Zealand
• Provide monitoring of outcomes from
international randomised trials on prostate cancer
screening and clinical management to decrease
harms from screening
Table 3-4:
Figure 3-4: Mortality rate of prostate cancer in New Zealand 1970-
2008.

• Work to assess the current cost of prostate
cancer service provision
In 2012 the Ministry of Health set up the Prostate
Taskforce to review the diagnosis and management
of prostate cancer in New Zealand men. This
Taskforce has released its report and
recommendations [10, 11]. The Taskforce report
covers the whole spectrum of prostate cancer
management, whereas our study has concentrated
on the diagnosis and management of men with
localised prostate cancer.
References
1. Hardie C, Parker C, Norman A, Eeles R, Horwich
A, Huddart R, Dearnaley D. Early outcomes of
active surveillance for localized prostate cancer.
BJU Int. 2005 April; 95 (7): 956-60.
2. Roemeling S, Roobol MJ, Postma R, Gosselaar
C, van der Kwast TH, Bangma CH, Schröder FH.
Management and survival of screen-detected
prostate cancer patients who might have been
suitable for active surveillance. Eur Urol. 2006
Sep; 50(3):475-82.
3. Roemeling S, Roobol MJ, de Vries SH, Wolters T,
Gosselaar C, van Leenders GJ, Schröder FH.
Active surveillance for prostate cancers
detected in three subsequent rounds of a
screening trial: characteristics, PSA doubling
times, and outcome. Eur Urol. 2007 May;
51(5):1244-50.
4. Johansson J,Holmberg L, Johansson S,
Bergström R, Adami H. Fifteen-Year Survival in
Prostate Cancer: A Prospective, Population-
Based Study in Sweden. JAMA. 1997;
277(6):467-471.
5. Johansson J, Andrén O, Andersson S, Dickman
P, Holmberg L, Magnuson A, Adami H. Natural
History of Early, Localized Prostate Cancer.
JAMA. 2004; 291(22):2713-2719
6. Obertova Z, Brown C, Holmes M, Lawrenson R.
Prostate cancer incidence and mortality in rural
men – a systematic review of the literature.
Rural and Remote Health 2012; 12:2039.
7. Bill-Axelson A, Holmberg L, Ruutu M, Häggman
M, Andersson S. O, Bratell S, Spångberg A,
Busch C, Nordling S, Garmo H, Palmgren J,
Adami H, Johan Norlén B, Johansson J. Radical
prostatectomy versus watchful waiting in early
prostate cancer. New England Journal of
Medicine. 2005; 352(19), 1977-1984.
8. Gore J, Kwan L, Lee S, Reiter R, Litwin, M.
Survivorship beyond convalescence: 48-month
quality-of-life outcomes after treatment for
localized prostate cancer. Journal of the
National Cancer Institute. 2009; 101(12), 888-
892.
9. Select Committee Report. Inquiry into early
detection and treatment of prostate cancer:
Report of the Health Committee. 49th
Parliament. 2011 July. House of
Representatives
10. Prostate Cancer Taskforce. 2012. Diagnosis and
Management of Prostate Cancer in New
Zealand Men: Recommendations from the
Prostate Cancer Taskforce. Ministry of Health.
Wellington, New Zealand.
11. Ministry of Health. 2013. Prostate Cancer
Awareness and Quality Improvement
Programme: Improving outcomes for men with
prostate cancer. Wellington: Ministry of Health.

17
4. PUTTING THE MIDLAND PROJECT
IN CONTEXT: UNDERSTANDING
PROSTATE CANCER TRENDS
NATIONALLY, REGIONALLY AND
BY ETHNICITY
Prostate cancer is the most commonly registered
cancer (28% of male cancer registrations) and the
third most common cause of male cancer deaths
(15%) among New Zealand men [1]. As the world
population is ageing, it is predicted that prostate
cancer will become a leading cause of cancer
deaths [2].
From 1998 to 2008 only five men younger than 40
years were registered with prostate cancer in New
Zealand [this study]. The incidence of prostate
cancer is generally extremely rare before the age of
40 years [1]. Therefore, for the purpose of our
study we have considered only men aged 40 years
and older as the population at risk. All calculations
following this statement, including GLOBOCAN
rates, are based on populations of men aged 40+
years [3].
Figure 4-1: Age-standardised (WHO men 40+ years) incidence rates
of prostate cancer for New Zealand, Australia, USA, Canada, UK,
Sweden and Germany [3].
New Zealand has one of the highest age-
standardised incidence rates of prostate cancer in
the world, which is largely attributed to high
screening rates for prostate cancer [3-5] (Figure 4-
1). Furthermore, the mortality rate due to prostate
cancer in New Zealand is comparably high,
exceeding death rates in Canada and the USA, and
the UK in particular, which has a low prostate
cancer incidence and low screening rates [3]
(Figure 4-2).
Figure 4-2: Age-standardised (WHO men 40+ years) prostate cancer
mortality rates for New Zealand, Australia, USA, Canada, UK,
Sweden and Germany [3].
Prostate cancer incidence rates provide
information on the uptake of screening and access
to early detection in a population. However, they
may also reflect regional differences in cancer
registration practices. The incidence rate of
prostate cancer in New Zealand increased
dramatically (Figure 4-3) since PSA testing became
available in 1993 [6].
Although mortality has been decreasing slightly
since 1996 [1], it is unclear whether this decline
may be attributed to PSA screening and/or to
improvements in treatment [7, 8].
Figure 4-3: Annual age-standardised (WHO) prostate cancer
incidence and mortality rates in New Zealand men [3].
In New Zealand, prostate cancer is the cancer with
the highest 5-year prevalence when compared with
0
50
100
150
200
250
300
350
New Zealand
Australia
USA
Canada
UK
Sweden
Germany
Age-standardised incidence rate per
100,000
0
10
20
30
40
50
60
70
New Zealand
Australia
USA
Canada
UK
Sweden
Germany
Age-standardised mortality rate per
100,000
0.0
20.0
40.0
60.0
80.0
100.0
120.0
140.0
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
2009
Age-standardised (WHO) rates
Registrations Deaths

18
other common cancers, such as breast cancer in
women or colorectal cancer in both men and
women [3] (Figure 4-4).
Figure 4-4: Five-year prevalence of common cancer in New Zealand
[3].
For the purpose of our study, we used national
data to “set the scene” for more detailed regional
analyses. We used incidence and survival data to
assess temporal trends and also to explore the
effects of ethnicity and region on these outcomes.
Mortality rates were not used because in the case
of prostate cancer mortality rates are considered
to be an inconsistent measure. This is due to the
fact that annual death rates represent a mixture of
cases, some of which were diagnosed decades ago
and some of which were diagnosed recently.
Therefore, annual mortality rates are liable to the
effects of period-specific changes in incidence rates
and treatment options [9].
The disadvantage of using survival as an outcome
measure is that, in contrast to mortality, survival
can be improved not only by preventing or curing
the disease but also by early diagnosis and, in the
case of prostate cancer, by over-diagnosis.
Therefore, we would not be able to assess the
extent to which any of the three factors –
screening, treatment and early diagnosis – drives
the result. However, using survival as an outcome
measure allowed us to address our main aim for
this part of the study, which was to assess current
trends in outcomes and differences between ethnic
groups and regions.
Aim
The aim of our study was to assess temporal trends
in prostate cancer incidence and survival, and to
explore differences between Cancer Networks, and
between Māori and non-Māori men. Since most of
our research was undertaken in the Midland
Cancer Network (MCN), the comparison of
registration and survival rates between Cancer
Networks (CNs) will allow us to assess the situation
in the MCN with respect to the national
framework. We can also estimate to what extent
the results obtained within the MCN may be
extrapolated to other regions. Individual factors,
such as age, ethnicity, geographical residence and
socio-economic status were also explored since
they may have an effect on registration and
survival rates.
The MCN covers the District Health Boards (DHBs)
of the Waikato, Bay of Plenty and Lakes regions.
The MCN has a leadership, facilitation and co-
ordination role in bringing together and working
with stakeholders across organisational and service
boundaries to reduce the impact of cancer, reduce
inequalities in care and improve the experience
and outcomes for people with cancer.
In July 2012 the Tairawhiti DHB joined the MCN. By
this time, however, the data collection for our
study had been completed. Thus, our analysis only
included data from the three original DHBs. These
three DHBs have a combined population of
680,000, of whom 24% are of Māori descent [10].
Four major hospitals are located in the region
covered by the MCN: Waikato Hospital (the
regional Cancer Centre), Tauranga Hospital,
Whakatane Hospital and Rotorua Hospital. These
hospitals all offer specialist urological services.
Approximately 45% of the population within these
three DHBs lives rurally or in a minor urban centre
[11].

19
Methods
We created a study sample of men diagnosed with
prostate cancer between 1 January 1996 and 31
December 2010. We used two main information
sources for data extraction: the New Zealand
Cancer Registry (NZCR) and the Mortality Collection
(MORT). Data linkage by the National Health Index
(NHI) number was used to ascertain the cause of
death for deceased men identified from the NZCR.
The data on vital status from MORT were available
from 1 January 1996 to 25 May 2011 (the most
recent data available at the time of request).
The final study population included 37,529 men
from the original 41,583 men after men aged
younger than 40 years at the time of diagnosis,
diagnosed at death, of unknown ethnicity and/or
with domicile abroad were excluded. Furthermore,
cases with morphology codes not consistent with
adenocarcinoma of the prostate were excluded.
Predictor variables
Age at diagnosis was used as a continuous variable
as was year of diagnosis. Prioritised ethnicity was
used in the analysis. Prioritised ethnicity is assigned
as Māori if one of the three possible self-identified
ethnicity responses is Māori. Men not identified as
Māori were described as non-Māori. In this group,
95.8% were NZ or other Europeans, 2.4% Pacific
Islanders, 1.5% Asians and 0.03% of other ethnicity.
Extent of disease is one of the major confounding
factors when analysing cancer survival. In the NZCR
the extent of disease at diagnosis is coded as B for
localised disease, C for invasion of adjacent tissues
or organs, D for invasion of regional lymph nodes, E
for distant metastases and F for unknown extent.
Unfortunately, the extent of disease at diagnosis
has been listed as known for only about one
quarter of prostate cancer patients. Therefore, we
used extent as a contributing factor in our analyses
but a sub-group analysis was not attempted.
Domicile (residence) at diagnosis from the NZCR
was used to assign each patient to the New
Zealand Index of Deprivation 2006 [12]. The
NZDep06 is a measure derived from nine variables
(income, benefit receipt, single parent family,
home ownership, employment, qualifications,
living space, access to communication and to
transport) collected in the Statistics New Zealand
2006 Census of Population and Dwellings and
provides a summary deprivation score ranging
from 1 (least deprived) to 10 (most deprived) for
small geographical areas (with a resident
population of approximately 100 people) [13]. For
the purpose of this study, the deciles have been
collapsed into quintiles.
Domicile at diagnosis was also used to classify each
patient into the following urban/rural categories:
main urban area, satellite urban area, independent
urban area, rural area with high urban influence,
rural area with moderate urban influence, rural
area with low urban influence, and highly
rural/remote area. This urban/rural classification
was developed in 2004 using the 2001 Census
meshblock patterns and the Statistics New Zealand
standard classification, which was based on
population size only by adding a measure of the
degree of urban influence to the respective areas
[Statistics New Zealand 2005]. This new measure
was determined by the usual residence and
workplace addresses of the employed population
in the area. For the analysis, the seven categories
were further grouped into 1) main urban area, 2)
urban influence (satellite urban area, independent
urban area, rural area with high urban influence),
and 3) rural/remote area (rural area with moderate
urban influence, rural area with low urban
influence, highly rural/remote area).
New Zealand is divided into four CNs: Northern
(NCN), Midland (MCN) and Central (CCN) on the
North Island, and the Southern (SCN) covering the
whole of the South Island. Table 4-1 lists the four
CNs with their respective DHBs. The DHB domicile

20
from the NZCR was used to assign each patient to
one of the four CNs.
Table 4-1: List of DHBs by Cancer Network.
Outcome variables
The age-specific and age-standardised incidences
of prostate cancer were calculated by year of
diagnosis. The Census 2001 New Zealand male
population aged 40+ years was used as the
population at risk (denominator) for the
standardisation. Men aged younger than 40 years
were not considered as being at risk of prostate
cancer.
Age-standardisation is used to enable comparisons
of groups that differ with regard to their age
structure, such as Māori and non-Māori groups in
New Zealand. Direct standardisation based on the
New Zealand population was used in our study.
Age is an important determinant in prostate cancer
since the incidence increases with age [14],
therefore age-specific rates were also analysed.
All-cause and prostate cancer-specific survival were
calculated from the date of diagnosis to the date of
death. Survival time after diagnosis was measured
in months. Men who were still alive on the day of
last follow-up (25 May 2011) were censored. For
the cancer-specific mortality analysis, men who
had prostate cancer listed as the underlying cause
of death were considered as cases, while men who
died of causes other than prostate cancer or were
still alive at the date of last follow-up were
censored.
Statistical analysis
The differences in the distribution of population
characteristics of men with prostate cancer
between the MCN and the other three CNs and
between Māori and non-Māori men were tested
using the chi-square statistic.
One-year and five-year survival for men in the MCN
compared with those in the other three CNs and
for Māori compared with non-Māori men were
estimated using the Kaplan-Meier method, and the
equality of survivor functions was compared by log-
rank test.
Cox proportional hazard regression models were
used to estimate the relative risk of dying from any
cause and from prostate cancer for men in the
MCN (compared with the other three CNs) and
Māori men (compared with non-Māori men)
before and after adjustment for age, diagnosis
years, residence, and socio-economic status.
Ethics approval for the access and use of the data
from the national databases (NZCR and MORT) was
granted by the Chairperson of the New Zealand
Multi-Region Ethics Committee (Ref. No.
MEC/11/EXP/044).
Results and discussion
Study population
Our study population included 37,529 men, of
whom 5748 (15.3%) resided in the MCN at the time
of diagnosis, and 1916 (5.1%) were Māori.
Appendix tables 9-1 and 9-2 summarise patient
characteristics by CN and ethnicity.
A higher proportion of Māori men were registered
with prostate cancer in the MCN compared with
the other three CNs. The MCN and SCN had similar
proportions of men living in rural/remote areas,
while the NCN and CCN had fewer men in this area.
The proportion of men in the most deprived
quintile was higher in the MCN than in the other
three CNs. A lower proportion of men were
diagnosed between 1996 and 2000 in the MCN
compared with the other CNs. The number of new
registrations continually increased up to the most
recent period (2006-2010) in the MCN, while no
such obvious trend was observed in the other three

21
CNs. Men in the MCN were more likely to die due
to prostate cancer than those in the NCN, while
they were less likely to die of other causes than
men in the SCN.
More Māori men were diagnosed under the age of
70 years compared with non-Māori men. Māori
men were more likely to reside in rural/remote
areas and to be in the most deprived quintile.
Māori men were more likely to die during the
follow-up period, and when they died they were
more likely to die of prostate cancer than non-
Māori men. The ratio of Māori men dying of other
causes to those dying of prostate cancer was 1,
while in non-Māori men this ratio was 1.4; this
indicates that non-Māori men were more likely to
die of causes other than prostate cancer.
Since age is an important factor in the natural
history of prostate cancer and also in the follow-up
of patients, particularly regarding treatment
options [15, 16], we also summarised the patient
characteristics by two age groups, under 70 years
and over 70 years at the time of diagnosis (see
appendix Table 9-3). Men under the age of 70 years
were more likely to live in rural/remote areas, and
to be in the least deprived quintile. More men
were diagnosed before the age of 70 years
between 2006 and 2010, while an opposite trend
was observed between 1996 and 2000. Naturally,
younger men were more likely to be alive at the
end of the follow-up. A similar proportion of men
aged less than 70 years at diagnosis died due to
prostate cancer and other causes, while a higher
proportion of men aged 70+ years died of other
causes than of prostate cancer.
To summarise, men diagnosed with prostate
cancer between 1996 and 2010 in the MCN were
more likely to be Māori, live in rural/remote areas
and in the most deprived quintile and die of
prostate cancer than men in the other Cancer
Networks. We also found that Māori men were
more likely than non-Māori men to reside in
rural/remote areas and in the most deprived
quintile and to die of prostate cancer. Therefore,
the differences between the MCN and the other
CNs may have been largely driven by the higher
proportion of Māori men with prostate cancer
identified in the MCN.
In addition, Māori men tended to be younger
(under 70 years) at the time of prostate cancer
diagnosis compared with non-Māori men, and
while younger men are naturally less likely than
older men to die, a similar proportion of men
younger than 70 years died of prostate cancer and
of other causes, while in men older than 70 death
was more likely due to causes other than prostate
cancer.
Incidence
Figure 4-5: Age-specific incidence rates of prostate cancer in our
cohort.
Temporal trends in the incidence of a disease
reflect screening behaviour and changes in
diagnostic methods. Figure 4-5 shows age-specific
incidence rates of prostate cancer in our cohort of
New Zealand men diagnosed between 1996 and
2010. From 1996 to 2003 there was a clear decline
of new diagnoses of prostate cancer in men aged
70+ years. On the other hand, after 2000 there was
a slight increase in new cases detected in men
younger than 54 years. There were two relatively
distinct peaks in new prostate cancer diagnoses in
men aged 55 to 69 years between 2000 and 2001
and then between 2007 and 2009.
0.0
200.0
400.0
600.0
800.0
1000.0
1200.0
1400.0
1600.0
1800.0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Age-specific in cidence rate per 100,000
40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 80–84 85+

22
The first peak coincides with intensified cancer
control debate in New Zealand and also with
advances in prostate cancer detection, especially in
biopsy techniques [7, 17]. In addition, between
1997 and 2000 there were several patient and
physician surveys concerning PSA testing and
prostate cancer detection in New Zealand, which
may have resulted in an increase in PSA testing and
thus prostate cancer diagnosis [18, 19, 8]. There is
anecdotal evidence that the second peak in 2007-
2009 may be associated with intensification of
prostate cancer awareness campaigns such as Blue
September and Movember in New Zealand,
prompting younger men (aged 40-69 years) in
particular to get their prostate health checked [20].
Interestingly, the incidence rates in Māori men
differed slightly from those in non-Māori (Figures
4-6 and 4-7). The incidence of new prostate cancer
cases has been declining with time in both groups.
However, the increase observed between 2007 and
2009 was driven mainly by non-Māori men.
Figure 4-6: Age-standardised (NZ men aged 40+ years from 2001
Census) incidence rates total and by ethnicity.
Although a small peak occurred in Māori men in
2007, the incidence decreased again after this.
When the curves were divided by age groups, the
downward trend for older men and increasing
trend in younger men was similar for both Māori
and non-Māori men, but Māori men did not follow
the upward trend resulting in the 2009 peak in
non-Māori men. It seems that non-Māori men
were more likely to follow the awareness
campaigns, which prompted them to get a prostate
check-up.
Figure 4-7: Age-standardised (NZ men aged 40+ years from 2001
Census) incidence rates by ethnicity and age group.
The temporal trends varied slightly by CN (Figure 4-
8). Interestingly, in the MCN a marked decrease in
new registrations occurred between 1998 and
2000, while in the other three CNs the number of
new cases increased significantly during that
period. There was generally a slight increase in new
registrations since 2006 in all four CNs, although
the curve was relatively flat in the SCN, while in the
MCN and CCN the number of new registrations
peaked in 2009.
Figure 4-8: Age-standardised (NZ men aged 40+ years from 2001
Census) incidence rates by Cancer Network.
It is assumed that the number of new prostate
cancer cases positively correlates with the number
of PSA tests undertaken in the population. In 2010,
fewer PSA tests were ordered in the SCN and CCN,
the CNs with the highest incidence rates of
prostate cancer in that year, while the highest
number of PSA tests was ordered in the NCN,
which had the lowest prostate cancer incidence
0.0
50.0
100. 0
150. 0
200. 0
250. 0
300. 0
350. 0
400. 0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Age-standardised incidence rate p er 100 ,000
Maori non-Maori Total
0
300
600
900
1200
1500
1800
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Age-standrdised incidence rate per
100,000
Maori 40-54y Maori 55-74y Maori 75+y
non-Maori 40- 54y non-Maori 55-74y non- Maori 75+y
0.0
50.0
100.0
150.0
200.0
250.0
300.0
350.0
400.0
450.0
500.0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Age-standardised incidence rate per 1 00,000
MCN NCN CCN SCN

23
[21] (Figure 4-9). This trend indicates that
monitoring by PSA testing increases in men with
existing prostate cancer, but also that a large
proportion of PSA tests do not result in the
identification of a new cancer case.
Figure 4-9: Number of PSA tests per 100 men aged 40+ years by
Cancer Network [21].
Survival
We used the Kaplan-Meier method to estimate the
1-year, 5-year and 10-year all-cause and cancer-
specific survival by CN and by ethnicity (see
appendix Table 9-4). This method shows what
proportion of men survived the respective periods
of time. Approximately 90% of all men survived the
first year after prostate cancer diagnosis; 95%
when cancer-specific survival was considered. Of
men who died of any cause, approximately 70%
were still alive after 5 years and 50% after 10 years.
Of the men who subsequently died of prostate
cancer, 85% were alive after 5 years and 75% after
10 years. The proportion of men surviving was
similar among all CNs, but a higher proportion of
men were still alive in the NCN compared with the
other CNs.
Māori men had consistently worse all-cause
survival, with 87% surviving 1 year, 59% 5 years
and 35% 10 years, compared with 91%, 70% and
49% of non-Māori men, respectively. A similar
pattern was observed for cancer-specific survival.
We used the Cox proportional hazards regression
models to estimate hazard ratios for the MCN
compared with the other three CNs and for Māori
compared with non-Māori men, while successively
adjusting for variables such as age at diagnosis,
year of diagnosis, extent of disease at diagnosis,
residence and socio-economic status. In this report
we present the results from only the unadjusted
model and the full model (see appendix Table 9-5).
Based on the unadjusted model we found that the
hazard ratios for all-cause survival were similar for
men in the MCN, CCN, and SCN, while men with
prostate cancer in the MCN were 19% more likely
to die of any cause compared with those in the
NCN. The cancer-specific hazard ratios showed that
men in the MCN were 31% more likely to die of
prostate cancer than men in the NCN, 10% more
likely to die than men in the CCN and 15% more
likely to die than men in the SCN. After adjusting
for age, year of diagnosis, extent of disease at
diagnosis, ethnicity, residence and socio-economic
status, men with prostate cancer in the MCN were
12% more likely to die of any cause than those in
the NCN. When cancer-specific survival was
considered, men in the MCN had 23%, 9% and 14%
worse chances of survival than men in the NCN,
CCN and SCN, respectively.
The unadjusted hazard ratio for all-cause survival in
Māori (compared with non-Māori) men diagnosed
with prostate cancer between 1996 and 2010 was
1.49 [95% CI; 1.40, 1.60], i.e. Māori men were 49%
more likely to die of any cause than non-Māori
men. The hazard ratio adjusted for age, year of
diagnosis, extent of disease at diagnosis, CN,
residence and socio-economic status was 1.72
[95% CI; 1.60, 1.84].
The unadjusted hazard ratio increased when
cancer-specific survival was considered, with Māori
men having 1.7-fold [95% CI; 1.54, 1.86] risk of
dying from prostate cancer compared to non-Māori
men. After adjustment for age, year of diagnosis,
extent of disease at diagnosis, Cancer Network,
0
5
10
15
20
25
30
35
40
45
50
Midland CN Northern CN Central CN Southe rn CN
Number of PSA tests per 100 men aged 40+ yrs in 20 10

24
residence, and socio-economic status the hazard
ratio was reduced to 1.64 [95% CI; 1.49, 1.82].
Since treatment options for prostate cancer are
highly dependent on age at diagnosis [15, 16], we
analysed cancer-specific survival by age groups
(<70 years, 70+ years). The hazard ratios from the
unadjusted model were similar for men aged <70
years at diagnosis in the MCN, CCN, and SCN, while
men with prostate cancer in the MCN were 28%
more likely to die of prostate cancer compared
with those in the NCN. When men aged 70+ years
at the time of diagnosis were considered, men in
the MCN had 30%, 17% and 24% worse survival
chances than men in the NCN, CCN and SCN,
respectively. In the full model, adjusted for age,
year of diagnosis, extent of disease at diagnosis,
residence and socioeconomic status, a similar
pattern was observed, with the differences
between the MCN and the other CNs reducing
slightly.
The unadjusted hazard ratio for cancer-specific
survival in Māori (compared with non-Māori) men
aged <70 years was 2.46 [95% CI; 2.13, 2.84], while
after adjustment for age, year of diagnosis, extent
of disease at diagnosis, CN, residence and socio-
economic status, the hazard ratio dropped to 1.59
[95% CI; 1.40, 1.81]. Māori men aged 70+ years at
diagnosis were 1.73-fold (unadjusted model) and
1.57-fold (model adjusted for age, year of
diagnosis, extent of disease at diagnosis, CN,
residence and socio-economic status) more likely
to die of prostate cancer than their non-Māori
peers.
Figures 4-10 and 4-11 show cancer-specific survival
by years of diagnosis (1996-2000, 2001-2005, 2006-
2010), CN and ethnicity, respectively. The survival
improved over time in all CNs as well as in Māori
and non-Māori men. However, the survival
differences, particularly between Māori and non-
Māori men remained constant.
Conclusions
Incidence rates of prostate cancer were similar
among the CNs, but higher rates of PSA test use
was observed in the NCN. Without reliable
information on the extent of disease at diagnosis,
the number of men being PSA tested may be used
as a proxy for the number of prostate cancer cases
detected early (i.e. with localised prostate cancer).
Men with localised prostate cancer have a good
prognosis, with a high proportion surviving more
Cumulative survival
Months
1
2
3
Legend
1=1996 to 2000 (CCN
overlapped by SCN)
2=2001 to 2005
3=2006 to 2010 (MCN
overlapped by NCN 01-06)
Months
Cumulative survival
Legend
1=1996 to 2000
2=2001 to 2005
3=2006 to 2010
1
1
2
2
3
3
Figure 4-10: Cancer-specific survival by years of diagnosis and
Cancer Network.
Figure 4-11: Cancer-specific survival by years of diagnosis and
ethnicity.

than 10 years without treatment [22]. Therefore,
the better survival in men in the NCN can be
explained to some extent by early detection rather
than by differences in treatment. This statement is
also corroborated by the particularly high
proportion of men surviving 10 years in the NCN
compared with the other three CNs.
Men in the MCN were more likely to die of prostate
cancer than men in any of the other three CNs.
These differences remained after adjusting for
potential confounders, such as age, year of
diagnosis, extent of disease at diagnosis, ethnicity,
residence and socio-economic status. Therefore, it
seems that the findings are contributory to the
observed survival disparities.
By analysing survival differences for men younger
and older than 70 years at diagnosis separately, we
found that the differences between the MCN and
the other three CNs in cancer-specific survival were
driven by the older age group. Since curative
treatment is mostly offered only to men younger
than 70 years old [23, 15, 16], it seems that other
factors such as co-morbidities may explain the
survival differences between CNs in older patients.
The number of new registrations was found to be
lower for Māori men than for non-Māori men.
However, Māori men were more likely to die with
and of prostate cancer compared with non-Māori
men. When all-cause survival was considered, the
adjusted hazard ratio was higher than the
unadjusted value, indicating that there were other
factors (for which the model was not adjusted)
contributing to the survival disparity, such as co-
morbidities and treatment modalities. However,
the unadjusted and adjusted cancer-specific hazard
ratios were similar, which suggests that the
differences in all-cause survival were most likely
due to factors other than treatment for prostate
cancer.
We also analysed cancer-specific survival by
diagnosis years, and we found that there was an
improvement in survival particularly after the year
2000, which coincides with changes in treatment
for prostate cancer in Australasia and may be also
attributed to earlier diagnosis due to higher public
awareness about PSA testing [7, 8]. However,
despite the fact that survival improved in both
Māori and non-Māori men, the survival gap
between these groups has not reduced with time,
which is concerning.
Based on our primary care study (chapter 5) we
know that Māori men are less likely to be tested for
prostate cancer [24]. However, the NZCR does not
contain enough information on the extent of
disease at diagnosis to draw conclusions on
whether Māori men are more likely to be
diagnosed with advanced disease, which would
reduce their survival chances compared with non-
Māori men. We have also found that other factors,
such as residence and socio-economic status,
contribute to survival disparities. Therefore, these
and other factors, including co-morbidities, will be
further explored on the regional level within the
MCN.
Recommendations
Most (80%) prostate cancer registrations are not
staged on the New Zealand Cancer Registry,
making interpretation of outcomes speculative.
1.1 Regional Collection
1.1.1 We recommend that the regional cancer
networks record basic information on all
men newly diagnosed with prostate cancer
in their region – including age, ethnicity,
domicile, PSA levels, cancer grade and
stage, presence of comorbidities, pre-
existing conditions and first treatment – in a
standardised format.

26
References
1. Ministry of Health. New Registrations and
Deaths 2006: Revised edition. Ministry of
Health; 2010. Wellington, New Zealand.
2. Baade PD, Youlden DR, Krnjacki LJ. International
epidemiology of prostate cancer: geographical
distribution and secular trends. Mol Nutr Food
Res. 2009; 53:171-84.
3. Ferlay J, Shin HR, Bray F, Forman D, Mathers C,
Parkin DM. GLOBOCAN 2008 v1.2. IARC
CancerBase No. 10, Lyon: International Agency
for Research on Cancer [internet], 2010 [cited
15 July 2011]. Available from:
http://globocan.iarc.fr
4. Hodgson F, Obertová Z, Brown C, Lawrenson R.
PSA Testing in General Practice. J Prim Health
Care. 2012; 4(3):199-204.
5. Obertová Z, Lawrenson R, Hodgson F, Brown C,
Stewart A, Tyrie L, et al. Screening for prostate
cancer in New Zealand general practice. J Med
Screen. 2013; 20: 49-51.
6. Smart R. PSA testing and DRE, TRUS scanning
with sector biopsy, improved histology, curative
treatments, and active surveillance for prostate
cancer: a success story for men’s health. N Z
Med J. 2008; 121(1287):57-68.
7. Smart R. Outcomes of transrectal ultrasound
scan of the prostate with sector biopsies for
323 New Zealand men with suspicion of
prostate cancer. N Z Med J. 1999; 112(1101):
465-69.
8. Chong CCW, Austen L, Kneebone A, Lalak A,
Jalaludin B. Patterns of practice in the
management of prostate cancer: results from
multidisciplinary surveys of clinicians in
Australia and New Zealand in 1995 and 2000.
BJU Int. 2006; 97: 975-80.
9. Feuer EJ, Merrill RM, Hankey BF. Cancer
surveillance series: Interpreting trends in
prostate cancer. Part II: Cause of death
misclassification and the recent rise and fall in
prostate cancer mortality. J Natl Rev. 2002;
21:17-27.
10. Statistics New Zealand. New Zealand All DHB
Estimated Resident Population 2006-2026.
Statistics New Zealand; 2007. Wellington, New
Zealand.
11. Statistics New Zealand. New Zealand: An
Urban/Rural Profile. Statistics New Zealand
[internet], 2005 [cited 11 November 2011].
Available from:
http://www.stats.govt.nz/urban-rural-
profiles/default.htm
12. Salmond C, Crampton P, Atkinson, J.
NZDep2006 Index of Deprivation. Department
of Public Health, University of Otago; 2007.
13. Salmond C, King P, Crampton P, Waldegrave C.
NZiDep: A New Zealand index of socioeconomic
deprivation for individuals. Social Science &
Medicine 2006; 62: 1474-85.
14. Narain V, Cher ML, Wood DP. Prostate cancer
diagnosis, staging and survival. Cancer
Metastasis Cancer Inst. 1999; 91(12):1025-32.
15. Bechis SK, Carroll PR, Cooperberg MR. Impact
of age at diagnosis on prostate cancer
treatment and survival. J Clin Oncol. 2011 Jan
10; 29(2):235-41.
16. Walter LC, Fung KZ, Kirby KA, Shi Y, Espaldon R,
O'Brien S, Freedland SJ, Powell AA, Hoffman
RM. Five-year downstream outcomes following
prostate-specific antigen screening in older
men. JAMA Intern Med. 2013 May 27;
173(10):866-73.
17. Cox B, Atkinson CH, Harvey VJ, Marshall B. The
need for a national cancer control strategy in
New Zealand. N Z Med J. 1999; 112(1101): 457-
59.
18. Durham J, Low M, McLeod D. Screening for
prostate cancer: a survey of New Zealand
general practitioners. NZ Med J. 2003;
116(1176).
19. Arroll B, Pandit S, Buetow S. Prostate cancer
screening: knowledge, experiences and
attitudes of men aged 40-79 years. N Z Med J.
2003; 116(1176):U477.
20. Blue September. $1 million achievement
celebrated for Blue September [internet]. 2012
[cited 22 November 2012]. Available from:
http://www.blueseptember.org.nz /news/$1-
million-achievement-celebrated-for-Blue-
September-62.php.
21. Ministry of Health. National Community
Referred Laboratory Data Warehouse; Sector
Services [Extracted October 2012].

27
22. Johansson J, Andrén O, Andersson S, Dickman
PW, Holmberg L, Magnuson A, Adami HO.
Natural history of early, localized prostate
cancer. JAMA. 2004; 291:2713-9.
23. Hall W, Ashesh JB, Ryu JK, Narayan S,
Vijayakumar S: The impact of age and
comorbidity on survival and treatment patterns
in prostate cancer: using the Charlson
Comorbidity Index to improve outcomes.
Prostate Cancer Prostatic Dis. 2005; 8:22-30.
24. Obertová Z, Scott N, Brown C, Hodgson F,
Stewart A, Holmes M, Lawrenson R. Prostate-
specific antigen (PSA) testing in Māori and non-
Māori men in New Zealand. [submitted].

28
5. PROSTATE-SPECIFIC ANTIGEN
TESTING IN GENERAL PRACTICE:
PATHWAYS OF CARE FOLLOWING
A PSA TEST
Prostate-specific antigen (PSA) testing is commonly
carried out in New Zealand, with over 350,000 tests
performed annually. Although there is no
organised prostate cancer screening programme in
New Zealand and prostate cancer screening in
general practice is not recommended by the
Ministry of Health, PSA testing is frequently used as
the first test to screen asymptomatic men for
prostate cancer [1]. However, PSA testing is also
useful in monitoring prostate cancer in men who
have had a previous raised PSA level or who have
an existing diagnosis and have been treated with
radical prostatectomy or radiotherapy, or are being
treated for metastatic disease [2]. PSA testing is
also used as a diagnostic aid in men with lower
urinary tract symptoms (LUTS).
Increasing prostate cancer screening has triggered
a series of problems, including increasing medical
costs. The published screening costs are outdated
and vary widely, and the studies often did not
clearly report which medical resources were
included and how they were valued [3].
There were two overarching aims for this phase of
the project. The first was to explore the patterns of
testing, including differences in care between
Māori and non- Māori and identifying reasons why
a PSA test was undertaken in Midland general
practices. We wanted to identify the pathways of
care following an abnormal PSA test result,
including what happens after a referral to a
specialist. The second aim was to explore the costs
of identifying a new case of prostate cancer by age
group, ethnicity and previous PSA testing history,
using data collected from the general practices.
METHOD
Thirty-six general practices in the Midland region
were approached during 2011 to participate in this
study. Clinics were purposefully selected with a
focus on rural and Māori populations. Thirty-one
clinics agreed to participate, with a total eligible
currently enrolled male population aged 40 years
and over of 36,740. We excluded 1006 (2.7%) men
aged over 40 years who had a co-existing diagnosis
of prostate cancer, leaving an eligible baseline
population of 35,958. Just over 5,000 were of
Māori ethnicity.
We sought permission from participating clinics to
access all local laboratory and DHB data for men in
our baseline population who had received a PSA
test during 2010. We
identified men who had
a PSA test during the
period 01 January 2010
to 31 December 2010
and the result of the
test. For these men we
looked at individual
frequency of testing and
velocity of PSA back to
2007. Testing rates
were analysed by
practice location (main
urban centre/rural,
District Health Board [DHB]), the ratio of patients
to general practitioners (GPs) in the practice and
whether the practice was a Māori provider. PSA
tests were categorised as raised if they exceeded
the age-specific levels recommended by Pathlab
(Table 5-1).
Medtech Search
The electronic general practice records (Medtech)
of men with a raised PSA test were then examined
to ascertain:
Age
Normal
value range
(ng/mL)
40-49y
0 - 2.5
50-59y
0 - 3.5
60-69y
0 - 4.5
70-79y
0 - 6.5
>80y
0 - 7.0
Table 5-1: Age-specific PSA
ranges recommended by Pathlab

29
• Was this a patient with known prostate
pathology (e.g. already diagnosed with prostate
cancer) or were they a new “case” requiring
further investigation?
• If they were a new “case” (i.e. a positive test),
did they present to the GP with symptoms or
were they identified through screening?
• Had the patient ever had a PSA test before and,
if so, when was it performed and what was the
result?
• At what level of PSA test were they referred for
specialist opinion/biopsy?
• If the patient was not referred for a specialist
opinion, what was the management plan for
that patient?
• If the patient had a biopsy, what was the result
of the biopsy?
• If the patient was found to have cancer, to
whom were they referred?
• If the patient was treated, what treatment did
they receive?
When we searched the general practice records
the reasons for PSA testing were defined into four
categories: A. screening; B. previous prostate issues
(including previously raised PSA); C. patient request
(included in screening for analysis); and D.
symptoms, including lower urinary tract symptoms
and erectile dysfunction.
To estimate costs, the patient’s National Health
Index (NHI) number was linked to the data used for
capitation payments. The information collected on
patients’ characteristics from the general practices,
including ethnicity and age was 100% complete.
Patients enrolled in general practices are required
to provide these data before their enrolment is
complete.
Cost estimation
We estimated direct medical costs in 2010 and
2011 from a health service perspective. Indirect
costs were excluded. A Decision Tree was
constructed to map the screening pathway and to
document the costs associated with each node (see
appendix Figure 9-1). Medical resources considered
in this study comprised initial general practitioner
consultations (the first consultation related to PSA
testing), follow up general practitioner
consultations, PSA tests, first specialist
assessments (FSA), follow-up specialist
consultations, prostate biopsies, pathology reports
of prostate biopsy and hospitalization due to
complications after prostate biopsy. (All costing
tables in appendix: Tables 9-6, 9-7, 9-8). The
volumes of the PSA tests, FSAs, prostate biopsies
and pathology reports were calculated from the
data we collected. The number of general
practitioner consultations was estimated based on
records of PSA tests ordered by general
practitioners. The number of follow-up specialist
consultations was estimated from the number of
prostate biopsies and PSA tests ordered by
specialists. A 2% complication rate [4] and a 4.87
days mean length of hospital stay for complications
of prostate biopsy [5] were assumed to quantify
the hospitalization after prostate biopsy.
The quantity of healthcare resources was
multiplied with the unit cost of each type of
medical resource to generate an aggregate cost.
The unit costs of medical resources are provided in
appendix Table 9-6, alongside the sources. The
subsidy per general practitioner consultation was
estimated by dividing the capitation rate by the
average number of general practitioner
consultations per patient [6] (see appendix Table 9-
6). The unit costs corresponding to different time
periods were converted into 2010 values (as the
base year of this analysis) by applying the NZ
Inflation Calculator developed by the Reserve Bank
(the central bank in NZ). All costs were valued in NZ
dollars (NZ$). The conversion rates per NZ dollar in
2010 were 0.540 European euro (€) and 0.447
Pound sterling (£), estimated from the prices and
purchasing power parities of different currencies

30
provided by Organisation of Economic Co-
operation and Development [7].
The time spent on discussion about PSA testing in
the initial GP consultation varied between from
general practices. This discussion is related to the
level of informed consent, ranging from almost no
time (ticking the box of a laboratory form) to the
whole consultation spent on discussing the harms
and benefits associated with prostate cancer
screening. Three percentages (20%, 50% and 100%)
of the cost of an initial GP consultation were
assumed to be attributed to prostate cancer
screening. This and further information and specific
detail on the method used for the cost calculations
have been published [8].
Ethical approval for the Midlands Prostate Cancer
study was gained through Northern Y:
NTY/10/09/070 (pilot) and NTY/11/02/019.
Results
The total enrolled population of men aged 40 years
and older in the 31 clinics was 35,958. There were
14% Māori (5,030) and 84% non-Māori (30,153) in
the sample (775 men of unknown ethnicity were
excluded).
The clinics were spread over the Midland region:
19 Waikato, eight Bay of Plenty, and four Lakes
DHBs. The population sizes of the communities
were well spread: <10,000 for 11 clinics; 10,000-
30,000 for nine clinics; and >30,000 for 11 clinics.
Thirteen clinics were in main urban areas and 18
were considered to be in rural locations. Rural
allowance was only applicable for 11 clinics. Rural
allowance criteria include general practices located
in settlements with <15,000 inhabitants and for
which the distance to the nearest urban centre is
>35 km.
There is only one Cancer Centre in the Midland
region, located in Hamilton. Therefore, the
distance from practice to Cancer Centre was
substantial, with half (15) of the clinics being
100km away or further. Nine clinics were 10-99km
from the Cancer Centre, while seven were located
less than 9km away.
In total, nine clinics were identified as being a
Māori Health Provider, defined by the Ministry of
Health as “a provider that is owned and governed
by Māori and is providing services primarily but not
exclusively to Māori”. Clinics where there were
communities of high Māori population were
purposefully selected and recruited. Overall, we
found strong representative numbers from Māori
men, with 14 clinics having >20% of patients being
Māori males aged 40 years and over.
Questionnaire
Figure 5-1: Response rate to questionnaire by practice.
A questionnaire was mailed out to all men within
the 31 practices with a first raised PSA test during
2010; the questionnaire was sent from and back to
the general practice. Out of the 1082 men who
had a raised PSA result during 2010, 391 were
identified as being ‘first-raised’ tests. However, 84
of these men were later identified as ineligible for
multiple reasons, including vital status,
comorbidities, death, previous prostate cancer
diagnosis, clinic transfer and lack of a current
contact address (Figure 5-1). In total 113 (37%)
patients did not respond. There were 194 eligible
1 2 3 4 5 6 7 8 9 1011 12 1314 1516 17 1819 2021 22 2324 2526 27 2829 3031
N/R 1 0 4 0 9 7 3 7 4 3 2 1 6 4 0 2 1 9 4 0 5 9 4 2 4 1 16 4 4 11 0
Ineligible 0 1 0 1 2 3 0 1 0 2 2 0 1 0 0 0 0 3 0 0 2 0 0 0 0 3 14 0 0 6 1
Received 6 2 13 4 9 19 2 4 5 10 3 1 1 11 1 0 2 8 4 2 12 14 2 1 3 9 23 21 421 8
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%

responses (63%). Seventeen men self-identified as
Māori (9%).
Aim 1: PSA testing in general practice
PSA testing and screening were defined for the
purposes of this study as the following:
Testing is used to determine the presence or
absence of prostate cancer in a patient who has
symptoms or is known to have a raised PSA
level and is being monitored.
Screening is done on an asymptomatic patient
and is either requested by the patient or done
by the GP – with or without discussion with the
patient.
Practices varied considerably in the way that they
tested/screened men. In eight practices, 30% or
more of men were tested in 2010, whereas in three
practices less than 10% of men were tested (Figure
5-2). Overall 9,344 men aged 40+ years had a PSA
test. While 15% (1,408/9,344) of tests were
performed because of symptoms or previous
prostate problems, the bulk of the tests
7,936/9,344 (85%) were considered to be for
screening.
Figure 5-2: Proportion of testing/screening by practice during 2010.
Overall 26% (9,344/35,958) of men 40 years and
older in the 31 general practices underwent PSA
testing during 2010. In all age categories, men who
were tested were more likely to have been
screened, rather than having been tested because
of symptoms or previous prostate problems. In
total, the asymptomatic screening rate was 22.1%
(7,936/35,958).
Figure 5-3: Proportion of testing/screening during 2010 by age and
ethnicity.
A considerable amount of screening was
undertaken on men aged 70+ years (24.4%) (Figure
5-3). The highest screening rates were observed in
men aged 60-69 years (31.5%) and in
asymptomatic men 70 years and older with no
prior history of a raised PSA result in the previous
three years (27.7%). This was also the case for 17%
of men aged 80+ years.
PSA testing was performed in significantly more
non-Māori (26.9%) than Māori men (13.0%) in
2010. Māori were 53% less likely to be tested than
non-Māori [1].
Elevated PSA
Patients were identified as having an elevated PSA
result using the laboratory guidelines (Table 5-1).
Overall, 1,082/9,344 (11.6%) of men had an
elevated PSA result (Figure 5-4). The proportion of
men who underwent testing for screening with an
elevated PSA result was 2.1% (170/7,936).
We found that elevated PSA tests were significantly
more commonly detected in screened men with no
previous tests compared with those tested prior to
2010 [9].
0
10
20
30
40
50
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Proportion of men tested/screened (%)
Screening Testing
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
Maori Non-Maori Maori Non-Maori
Men PSA tested in
2010
Men PSA screened in
2010
<70 years 70+ years Total

Figure 5-4: Proportion of elevated PSA during 2010 from
testing/screening by age group.
When tested for PSA, Māori men aged 40-69 years
were more likely than non-Māori to have an
elevated result. This was the same for screening
rates, with more non-Māori (22.4%) than Māori
men (10.9%) having been screened. For all men
aged 70 years or over, the screening rates
remained high regardless of ethnicity.
Frequency of screening
Figure 5-5: Previous PSA tests (2007-2009) in screened men.
Fifty seven percent of men screened in 2010 had a
record of at least one previous PSA test between
2007 and 2009 (Figure 5-5). Māori men who were
tested during 2010 were significantly less likely
than non-Māori to have had a PSA test in the
previous three years. We found that 43% of men
had no prior PSA test during the previous three
years. A quarter of the screened men in the 70-79
year age range had not had a PSA test in the
previous three years. Nearly 40% of men screened
in the 80+ year age range had not had a PSA test in
the previous three years.
Among the tested men, the overall proportion of
men without previous PSA tests between 2007 and
2009 was 38.7%, while 29.5% of men had two or
more PSA tests prior to 2010.
Rural patterns
Eighteen of the 31 general practices were classified
as ‘rural practices’. In total 47% of men
(16,951/35,958) were enrolled in rural clinics.
Rural practices had a larger proportion of Māori
men compared to practices in urban regions. Men
in rural practices were less frequently screened
than men in main urban centres (20.2% vs. 26.8%;
x2P<0.0001). Depending on the size of settlement,
the proportion of men who underwent PSA testing
fell by nearly 15% from the highest populated
locations to the smallest settlements (Figure 5-6).
Figure 5-6: Proportion of overall PSA testing and screening by
settlement size.
Among those screened, elevated PSA levels were
found in 2.6% of men in rural practices, compared
with 1.8% of men in main urban centres. Māori
were more likely to have a PSA test if they were
based in a main urban area than in a rural area
(14.1% vs. 11.7%) and this was the same for non-
Māori (26.6% vs. 21.2%).
Reduced screening rates were seen in practices
with more than the average number of patients per
0
5
10
15
20
25
30
35
<60yrs 60-69yrs 70-79yrs 80+yrs Total
%
Elevated results from testing
Elevated results from screening
0
10
20
30
40
50
60
70
80
90
100
<60yrs 60-69yrs 70-79yrs 80+yrs Total
Proportion of previous PSA tests %
no test 1 test 2+ tests
0
5
10
15
20
25
30
35
<10,000 10,000-29,999 30,000+
Proportion of men with PSA
test (%)
Tested Screened

33
GP (x2P<0.0001), and in Māori Health Provider
practices (x2P<0.0001). General practices in the
Lakes DHB had the lowest PSA screening rate
(21.2%), while the practices in the Bay of Plenty
DHB had the highest rate (26.0%).
Specialist Referral
Table 5-2: Median PSA level at referral (and non-referral) during
2010.
Median
PSA
Level
for
Referral
(TESTED
- ALL)
ng/mL
Median Level of
elevated PSA
levels for
Referral
43% (N=467)
ng/mL
Median level for
non-referral 57%
(n=615)
ng/mL
Age
Median
(min;
max)
Screened
(n=66)
Non-
Screened
(n=401)
Screened
(n=104)
Non-
Screened
(n=511)
40-
49y
3.2 (1.7;
9.1)
3.5
3.3
3.0
2.9
50-
59y
5.9 (2.7;
203.3)
6.1
5.3
3.8
5.0
60-
69y
7.5 (2.1;
170.3)
6.5
7.4
5.0
6.0
70-
79y
9.9 (1.9;
320.0)
10.7
9.8
8.0
8.4
>80y
16.6
(7.0;
409.6)
38.5
15.4
15.4
10.2
Overall, 43% (467/1082) of men with an elevated
PSA result during 2010 were referred by their GP to
a specialist (Table 5-2). The referral rate was 34.8%
for Māori men and 44.1% for non-Māori men (the
difference is not statistically significant). Fifty seven
percent of men who had an elevated PSA level
were not referred and were still being managed by
their GP. In general, the median level of referral
reflected the levels recommended by the Prostate
Taskforce. [11]
The Prostate Taskforce [11] recommendations for
referral to urologist (p. 23):
 men aged 50–70 years – when the PSA is elevated
to ≥4.0 ng/mL
 men aged 71–75 years – when the PSA is elevated
to ≥10.0 ng/mL
 men aged ≥76 years – when the PSA is elevated to
≥20 ng/mL
 men with a palpable abnormality in the prostate on
DRE
 significant PSA rise in a man whose PSA has
previously been low may warrant referral.
Of the men who were referred to a specialist, those
men aged 50-59 years were most likely to be
referred (over half (50.5%) of patients in this age
group). Overall, 16% of the total referrals were as a
result of GP screening. The majority of men (84%)
referred were identified because of symptoms or
previous prostate problems.
Referral
rate
Biopsy rate
Positive
biopsy
rate
40-49
years
18/44
(40.9%)
9/18
(50.0%)
5/9
(55.6%)
50-59
years
111/220
(50.5%)
81/111
(73.0%)
37/81
(45.7%)
60-69
years
187/398
(47.0%)
142/187
(75.9%)
79/142
(55.6%)
70-79
years
107/264
(40.5%)
57/107
(53.3%)
39/57
(68.4%)
80+
years
44/156
(28.2%)
13/44
(29.5%)
5/13
(38.5%)
Total
467/1082
(43.2%)
302/467
(64.7%)
165/302
(54.6%)
Table 5-3: Referral rates, biopsy rates and positive biopsy rates.
Table 5-3 shows the referral, biopsy and positive
biopsy rates for those men who were referred after
an elevated PSA level. Of those men who were
referred to a specialist, 302 were biopsied (64.7%).
56.3% Māori men were biopsied compared to
65.4% non-Māori men. Men in the 50-59 and 60-69
year age ranges were the most likely to be biopsied
(73% and 76% of referrals, respectively). The
proportions of men biopsied that were identified
by screening and symptoms were the same as for
referrals (16% and 84%, respectively). Of those
who underwent a biopsy, 165 men (55%) were

34
found to have a positive result. In Māori men
66.7% of the biopsies were positive compared to
54.3% in non-Māori men. Sixteen percent (27/165)
of detected cancers were identified by screening
and 1% (2/165) were identified without an
elevated PSA, on digital rectal examination (DRE).
In Māori men 66.7% of the biopsies were positive
compared to 54.3% in non-Māori men. The cancer
detection rate from men with elevated PSA test
was 13.0% for Māori men and 15.6% for non-Māori
men. None of these differences was statistically
significant. Most of the positive biopsies in both
Māori (58.3%) and non-Māori men (60.8%)
returned a Gleason score of 6 [1].
In total, 165/1082 (15.2%) of men with elevated
PSA tests were found to have prostate cancer.
Nearly 70% of men in the 70-79 year age range
were found to have a positive biopsy result. This
showed that 137 men had a negative biopsy;
however, these men are still at increased risk of
developing prostate cancer. In addition, 615/1082
(57%) of men who were not referred will need
follow-up in general practice.
Questionnaire
In the 31 clinics, 1082 men had at least one raised
PSA result during 2010. Of these 1082, 391 had a
first raised PSA result in that year. Once the
ineligible men were omitted (n=84), 307 (40 to
Māori; 267 to non-Māori) questionnaires were
mailed out by the general practice for patients to
fill out and return to their GP.
Findings from patient questionnaires
Table 5-4: Age and ethnicity
n/N (%)
40-49
years
50-59
years
60-69
years
70-79
years
80 plus
years
Māori
1/17
(5.9%)
5/17
(29.4%)
9/17
(52.9%)
2/17
(11.8%)
0
non-
Māori
9/177
(5.1%)
49/177
(27.7%)
69/177
(39.0%)
36/177
(20.3%)
14/177
(7.9%)
Total
10/194
(5.2%)
54/194
(27.8%)
78/194
(40.2%)
38/194
(19.6%)
14/194
(7.2%)
One hundred and ninety four eligible responses
were received (Table 5-4). Seventeen Māori (17/40,
42.5%) and 177 non-Māori (177/267, 66.3%)
responded.
PSA frequency
Fifty three percent of men identified that this was
the first time they had been PSA tested. Forty
percent of men said it was not their first test; (7%
unsure). Significantly more Māori men (p=0.0197)
identified that this was their first PSA test (82.4%)
compared with non-Māori (50.8%). [10]
Reasons for PSA
Twenty seven percent (53/194) of men said that
they had asked for the PSA test, while 66% of men
(128/194) felt that the testing was initiated by the
GP. Of those men who had their GP recommend
the test, 47.7% identified that they had some type
of symptom at the time of the test. Men aged 40-
49 years and 80 years plus were most likely to have
a test by their GP because of symptoms at 60.0%
and 53.8% respectively. Much of the testing in men
aged 70-79years (84.2%) and 80 years plus (92.9%)
was GP initiated. Māori men were just as likely as
non-Māori to identify that the test was suggested
by the GP, 64.7% and 67.2% respectively. [10]
For those men who self-initiated the test we asked
what their main reason was for doing this. Having
a family history of prostate cancer (18.9%; 10/53)
or being prompted by the media or a friend or
family member (47.2%; 25/53) were the main
reasons. [10]
The majority of men (54.1%; 105/194) said they did
not have symptoms at the time of the test, while
42.8% of men (83/194) stated they did have
symptoms. Ninety percent of men with symptoms
identified that they had LUTS. [10]
Digital Rectal Examination
141/189 (74.6%) identified that a DRE had been
performed at the time of their first raised PSA test
(Figure 5-7). Men in the 60-69 year age range were
the most likely to receive a DRE by their GP

35
(85.9%). Twenty-five percent of men (n=48)
identified they did not receive a DRE. The Prostate
Taskforce recommends that screening should be
done by both PSA testing and DRE. It should be
noted that in our study two asymptomatic men
with normal PSA levels were found to have
prostate cancer on DRE. [10]
Figure 5-7: Proportion of self-reported patient DREs at time of
raised PSA test during 2010.
Post-elevated PSA
Fifty eight percent of men (113/194) were referred
by their GP to see a specialist; 40.2% (78/194) of
men reported that they were not referred. Māori
men were significantly less likely to be referred
(p=0.0418) than their non-Māori counterpart at
35.3% and 60.5% respectively. The split between
the public and private setting was close to even at
46.9% and 44.2% respectively. In addition, three
men saw specialists in both the public and private
setting. [10]
For those men that did see a specialist, 65 men
(68%) received a biopsy. (Some men who had a
biopsy did not identify that they had been referred
by their GP). Forty four men (22.7%) were
monitored post-PSA testing by either the GP or a
specialist, or by both. The majority of men (69.0%,
134/194) thought that they were not currently
monitored. Of the men referred 20.4% went on to
receive an operation. [10]
For men who attended a private practice for their
first specialist appointment (78.4% 40/51) waited 4
weeks or less. For the men who went to a public
hospital, the wait times for 0-4 weeks and 4-8
weeks were 29.1 (16/55) and 43.6% (24/55)
respectively. [10]
These data and further information on