Men's health

These first Australian evidence-based guidelines will serve as a clinical aid to practitioners who provide services to men with infertility and will facilitate evidence-based care for the most common areas of male infertility

Darren J Katz · Liza O’Donnell · Robert I McLachlan · Tim J Moss · Clare V Boothroyd · Veena Jayadev · Sarah R Catford

A multisectoral approach and stronger multilevel government coordination are required to address the health impacts associated with proximity to mining and exposure to toxic chemicals

Javier Cortes‐Ramirez · Ruby N Michael · Leisa‐Maree Toms · Melissa Haswell

Health care professionals caring for men with prostate cancer starting ADT should ensure that their bone health is routinely assessed

Mariya F Hamid · Amy Hayden · Tania Moujaber · Sandra Turner · Howard Gurney · Mathis Grossmann · Peter Wong

Over the past decade, detection and management of prostate cancer have evolved, with the focus now placed on harm minimisation, reducing overdiagnosis and avoiding overtreatment

Isabella SC Williams · Aoife McVey · Sachin Perera · Jonathan S O’Brien · Louise Kostos · Kenneth Chen · Shankar Siva · Arun A Azad · Declan G Murphy · Veeru Kasivisvanathan · Nathan Lawrentschuk · Mark Frydenberg

Modification of lifestyle behaviour, management of reversible risk factors and optimisation of existing medical conditions remain pivotal

Eric Chung · Michael Lowy · Michael Gillman · Chris Love · Darren Katz · Graham Neilsen

To the Editor: Undescended testis affects 2–4% of term male newborns.1 Clinical examination by an experienced clinician remains the most accurate method of assessing the position of the testis. It allows for the clear distinction between a retractile testis and palpable and impalpable undescended testes. In 2013, an evidence‐based statement on undescended testes was released jointly by Choosing Wisely and the American Urological Association which advocated against performing ultrasounds to investigate undescended testes due to their poor ability to localise non‐palpable testes.2 Unfortunately, this recommendation is not listed in the Australian Choosing Wisely website. Our study intended to improve awareness of the American Urological Association Choosing Wisely guidelines among Australian general practitioners and draw attention to the resources misspent due to lack of awareness. A retrospective audit was undertaken of 50 children referred in 2017 for an undescended testis to a single paediatric urologist in a private clinic. De‐identified data were extracted from the practitioner’s medical record system. The research ethics committee at the Sydney Adventist Hospital approved the publication of the audit. Of the patients referred with a diagnosis of an undescended testis, 35 testes (70%) were palpable in the scrotum on the day of consultation. However, 32 of 50 children (64%) already had an ultrasound by the time they were seen, with 51 testes (79%) labelled as undescended testis. Thus, more than two‐thirds of children had an ultrasound that was not needed, and the specificity was low at 27% (95% CI, 15–42%) (Box). About 159 379 boys were born in Australia in the study period.3 The cost of an ultrasound of the scrotum as per the Medicare Benefits Schedule was $109.50 (item 55048). Assuming an incidence of undescended testis of 2% and assuming ultrasounds were ordered in three times as many children, as happened in our study (15 undescended testes and 35 descended testes), the cost of unnecessary studies is calculated to be $1 047 120 (3 × 0.02 × birth cohort of 159 379 × $109.50). The numbers of Medicare claims for item 55048 have increased by 5% each year since 2010.4 Health budgets are finite, and expenditure should be linked to quality metrics. GPs and paediatricians are undoubtedly trying to be helpful by organising an ultrasound before the referral, but it is unnecessary. This letter is an attempt to continue the discussion with referring doctors to let them know that ultrasound is not required before referral for an undescended testis. This is a single clinic audit. We hope it will inspire larger population‐based audits to facilitate systemic change. Box – Ultrasound and examination findings Position of the testicle On examination inguinal On examination scrotal Total Inguinal ultrasound 16 35 51* Scrotal ultrasound 0 13 13 Total 16 48 64 * One testicle reported in the inguinal region on ultrasound was impalpable on examination.

Dharshini Selvarajah · Dermot McDowell · Susan Jehangir · Grahame Smith

The time for actively recommending the screening of asymptomatic men has passed

Justin J Coleman

To the Editor: The broadly accepted definition of a cancer survivor recognises that the survivorship begins at diagnosis.1 However, survivorship care pathways conventionally begin at completion of active treatment, presenting a challenge for addressing survivorship needs at diagnosis and for people living with incurable cancer.2 A revision of the concept of cancer survivorship is needed, placing the survivor at the centre of a dynamic experience of life after a cancer diagnosis and opening up the survivorship experience to persons at any stage of cancer and at any phase of their disease trajectory. Until now, clinical care guidelines and models of survivorship have typically not included consumer input, but rather have been developed principally through health professional expert consensus.3,4 In a novel approach from 2019–2020, a panel of 47 experts and consumers across Australia and New Zealand came together to define six key domains of survivorship care in a Prostate Cancer Survivorship Essentials Framework:5 health promotion and advocacy, shared management, vigilance, personal agency, care coordination, and evidence‐based survivorship interventions. These six domains reached high consensus as being essential, with the 26 elements within domains all rated as high importance. Almost one‐third of the 47‐member panel were cancer survivors working collaboratively with medical, allied health and nursing expert representatives. The degree of consensus in such a broad coalition is remarkable, underscoring the validity of the approach that reflects the lived experience driven by survivors’ preferences. Importantly, the central domain related to personal agency of a survivor as a key element that linked all others (Box) and all domains were framed around outcomes that mattered for the patient (eg, empowerment, information, shared decision making, care coordination, symptom management). While the framework was developed for prostate cancer survivorship, none of the elements were unique to prostate cancer, highlighting the potential relevance of the framework to other cancers. More broadly, this approach aligns with existing models of chronic disease management and frameworks of consumer engagement in care that are fundamental to the delivery of health care in Australia and New Zealand. We believe the essentials framework is applicable to other adult cancer patient cohorts and presents an opportunity to move forward on cancer survivorship in Australia, taking forward a unique consumer–practitioner model where the survivor is not just the passive object of care but an actor in their own health and an empowered and supported agent of change. Box – Prostate Cancer Survivorship Essentials Framework

Jeff Dunn · Bogda Koczwara · Suzanne Chambers

Measuring prostate‐specific antigen (PSA) levels is widely used for screening for the early diagnosis of prostate cancer.1 However, the value of PSA testing for reducing prostate cancer‐specific or all‐cause mortality in asymptomatic men is uncertain.2 The Prostate Cancer Foundation of Australia and the Cancer Council of Australia recommend that men aged 50–69 years be offered biennial PSA testing if they make an informed decision to be tested.1 We investigated age‐specific patterns of PSA testing and PSA levels in men aged 40 years or more without symptoms of prostate cancer. We analysed routinely collected data from 180 Victorian general practices, pooled by the data custodian, Outcome Health.3 We included all men who had attended the same practice at least three times during October 2016 – September 2018. We identified tested men and testing frequency from recorded PSA test results. PSA testing prevalence was defined as the number of men tested at least once divided by the total number of men in an age group. We evaluated the relationship between log‐transformed PSA levels and age as a continuous variable in a linear regression model. The Royal Australian College of General Practitioners National Research and Evaluation Ethics Committee (17‐008) and the Macquarie University Human Research Ethics Committee (5201700872) approved our study. A total of 142 016 male patients were identified. The proportion who underwent PSA testing at least once (prevalence) or at least twice during the study period increased with age: prevalence peaked with the 65–69 year age group (8132 men tested, 54% of age group), and the proportion of men tested at least twice with the 70–74 year age group (3159 men, 46% of age group) (Box 1). A total of 78 818 PSA test results were recorded during the study period; about one‐third were for men aged 60–69 years (25 496 tests, 32%). The median PSA level increased from 0.7 ng/mL (interquartile range [IQR], 0.5–0.9 ng/mL; 95th percentile, 1.7 ng/mL) for men aged 40–44 years to 1.9 ng/mL (IQR, 0.8–4.5 ng/mL; 95th percentile, 11.7 ng/mL) for men aged 85 years or more (Box 2). The median PSA level increased by 3.2% per year of age (95% confidence interval, 3.1–3.3%). We found that PSA testing prevalence, the proportion of men tested more than once within 24 months, and median PSA levels each increased with age. For men over 69 years of age, this could lead to further invasive tests and treatments, some of which may be unnecessary or cause harm. The high PSA testing prevalence among older men was similar to previous Australian reports (48% of men aged 70 years or more reported they had PSA tests in the preceding two years4), and the PSA levels matched current age‐specific 95th percentile reference ranges.5 Why patterns of testing are different to those recommended (ie, more frequently than biennial and beyond 69 years of age) cannot be explained by general practice data, but reasons may include patient expectations, fragmentation of care, and the persistence of old guideline recommendations. We have reported the most comprehensive snapshot of PSA testing in Australia based on electronic general practice data since the release of the current guidelines for PSA testing of asymptomatic men. Our study also showed that such data can be used to establish benchmarks for designing quality improvement activities and to promote evidence‐based decision‐making in general practice. Box 1 – Prostate‐specific antigen (PSA) testing for 180 Victorian general practices, October 2016 – September 2018, by age group* * Proportion of male patients in age group who were tested. It is recommended that men aged 50–69 years be tested once every two years. Numbers of patients in each age group are provided in the online Supporting Information. Box 2 – Number of prostate‐specific antigen (PSA) tests and median PSA test result levels, by age group table#t2 tbody td:nth-child(n+2) P. Pleft { text-align: center; } Age group (years) Number of tests PSA level (ng/mL) Median (IQR) 95th percentile 40–44 2685 (3.4%) 0.7 (0.5–0.9) 1.7 45–49 5894 (7.5%) 0.7 (0.5–1.0) 2.1 50–54 9544 (12.1%) 0.8 (0.5–1.2) 2.6 55–59 12 359 (15.7%) 0.9 (0.6–1.5) 3.7 60–64 12 944 (16.4%) 1.1 (0.6–2.0) 4.7 65–69 12 551 (15.9%) 1.3 (0.7–2.4) 5.5 70–74 10 999 (14.0%) 1.5 (0.8–2.8) 6.4 75–79 6440 (8.2%) 1.6 (0.8–3.3) 8.0 80–84 3327 (4.2%) 1.8 (0.8–3.6) 9.2 ≥ 85 2075 (2.6%) 1.9 (0.8–4.5) 11.7 All ages groups 78 818 1.0 (0.6–2.0) 5.4 IQR = interquartile range.

Guilherme S Franco · Rae‐Anne Hardie · Ling Li · Chisato Imai · Gorkem Sezgin · Julie Li · Adam McLeod · Christopher Pearce · Andrew Georgiou

To the Editor: In the retrospective study by te Marvelde and colleagues,1 the proportions of men in public and private health services receiving radical prostatectomy and curative external beam radiation therapy were examined in a multivariable logistic regression analysis. However, only age, International Society of Urological Pathology (ISUP) tumour grade, and comorbidity were studied. Prostate‐specific antigen (PSA) level and T stage are two of the strongest determinants of choice of treatment modality in clinical practice and have not been considered or discussed by the authors. We consider this to be a major flaw in this study and a failure of the peer‐review process to highlight this deficiency, which has a significant impact on the results and subsequent conclusions reached by the authors. Furthermore, patient comorbidities have not been adequately accounted for. The authors identify comorbidity as a factor influencing treatment, but they fail to assess and account for this variable in a reliable way. Victorian Admitted Episodes Dataset (VAED) data for the year preceding the prostate cancer diagnosis and up to 30 days after diagnosis were assessed to identify comorbid conditions other than cancer according to the Charlson Comorbidity Index, categorised as 0 or at least 1. This variable provided little discriminatory power (3% v 6%), and yet it was the only surrogate variable that accounted for comorbidity in the study’s key multivariable analyses. Additionally, the odds ratios for this variable in these analyses were not reported. It should be noted that 38% of the study population were men older than 70 years, but only 3.8% scored 1 or more on the VAED‐derived Charlson Comorbidity Index. We believe that the method used in this study to account for comorbidity is not adequately robust to provide an accurate picture of the patients’ general health status. The authors also cite the ProTect trial2 to suggest no major differences between active treatment options exist; however, they did not identify the vast differences in the disease characteristics of men in the ProTect trial compared with those included in their study (77% ISUP 1 and 2% ISUP 4/5 v 35% ISUP 1 and 18% ISUP 4/5). Moreover, te Marvelde and colleagues did not address clinical outcomes and have not presented evidence that the variation in treatment modalities between public and private services has had a negative impact on the final clinical outcome. Outcomes data can be helpful in identifying systematic shortcomings, inequities and barriers to just health care, but the authors missed the opportunity to highlight these issues. They concluded that the treatment of people with cancer should be consistent, safe, of high quality and evidence‐based, but did not provide evidence that the current practice is to the contrary.

Stephen Mark · Prem Rashid · Peter Heathcote · Kamran Zargar Shoshtari

Prostate cancer specialists working in collegiate, multidisciplinary teams are most likely to provide the best outcomes for patients

Henry H Woo · Amy Teh

Objective: To assess the demographic, social, and clinical characteristics of young Australians who die by suicide. Design: Retrospective analysis of National Coronial Information System (NCIS) data. Setting, participants: People aged 10–24 years who died by suicide in Australia during 2006–2015. Main outcome measures: Demographic, social, and clinical characteristics of young people who died by suicide; circumstances of death recorded in the NCIS. Results: 3365 young people died of suicide during 2006–2015 (including 2473 boys and men, 73.5%); 1292 people (38.4%) lived in areas of greater socio‐economic disadvantage. Free text reports were included in the NCIS for 3027 people (90%), of whom 1237 (40.9%) had diagnosed mental health disorders and 475 (15.7%) had possible mental health disorders. Alcohol consumption near the time of death was detected in 1015 of 3027 cases (33.5%); histories of self‐harm were recorded in 940 cases (31.1%) and of illicit substance misuse in 852 (28.1%). Adverse life events included history of abuse or neglect (223, 7.4%), suicide of relatives, friends, or acquaintances (202, 6.7%), and financial difficulties (174, 5.8%). Conclusions: Three‐quarters of the young people who died by suicide were boys or young men, and 57% had diagnosed or possible mental health disorders, suggesting that the mental health and wellbeing of young Australians should be a key target for youth suicide prevention. To reduce the number of youth suicides, it is imperative that prevention strategies target the mental health and psychosocial stressors that lead to suicidal crises in young people.

Nicole TM Hill · Katrina Witt · Gowri Rajaram · Patrick D McGorry · Jo Robinson

More evidence is required to explain the differences in cancer treatment reported by data linkage studies

Ian N Olver

Objective: To compare treatments for localised prostate cancer for men diagnosed in private and public health services in Victoria. Design: Retrospective analysis of Victorian Cancer Registry data linked to population‐based administrative health datasets. Setting, participants: 29 325 Victorian men diagnosed with prostate cancer during 2011–2017. Main outcome measures: Proportions of men in private and public health services receiving radical prostatectomy (with or without curative radiation therapy) or curative external beam radiation therapy alone within 12 months of diagnosis. Results: After adjusting for age, tumour classification and comorbidity, men diagnosed in private health services received radical treatment more frequently than men diagnosed in public health services (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.31–1.49). The proportion of private patients who underwent radical prostatectomy was larger than that for public patients (44% v 28%; OR, 2.28; 95% CI, 2.13–2.44) and the proportion of private patients who received curative external beam radiation therapy alone (excluding brachytherapy) was smaller (9% v 19%; OR, 0.45; 95% CI, 0.42–0.49). These differences were apparent for all International Society of Urological Pathology (ISUP) tumour grades. The magnitude of the difference for prostatectomy was greater for men aged 70 years or more; for radiation therapy alone, it was larger for those diagnosed before age 70. The differences between private and public services narrowed during 2011–2017 for men with ISUP grade 1 disease, but not ISUP grade 2–5 tumours. Conclusion: Prostate cancer treatment choices differ substantially between men diagnosed in private and public health services in Victoria. These differences are not explained by disease severity or comorbidity.

Luc te Marvelde · Roger L Milne · Colin J Hornby · Adam B Chapman · Graham G Giles · Ian E Haines

Australia needs to develop and implement policies to ensure that data are disaggregated, analysed and presented by sex and gender

The Sex and Gender Sensitive Research Call to Action Group

The intended audience has not arrived; there are no men

Kootsy Canuto

Mamils provide mutual midlife support for each other but may not contribute to increasing overall physical activity levels among adult Australians

Adrian E Bauman · Katrina Blazek · Lindsey Reece · William Bellew

Better biomarkers are needed to ensure early and accurate detection and prognosis of prostate cancer

Doug Brooks · Ian N Olver · Adrian J Esterman

Men who are being monitored may be more open to interventions for improving their general health and quality of life

David P Smith · Gary A Wittert

Almost three-quarters of men did not have follow-up investigations consistent with standard protocols

Melanie A Evans · Jeremy L Millar · Arul Earnest · Mark Frydenberg · Ian D Davis · Declan G Murphy · Paul Aidan Kearns · Sue M Evans

Contrary to the stereotype, remote workers in Australia experience high levels of psychological distress

Gordon B Parker AO

Objectives: To assess the prevalence and correlates of psychological distress in a sample of remote mining and construction workers in Australia. Design, setting: A cross-sectional, anonymous Wellbeing and Lifestyle Survey at ten mining sites in South Australia and Western Australia, administered at meetings held during 2013–2015. Participants: 1124 employees at remote construction, and open cut and underground mining sites completed the survey. Main outcome measures: General psychological distress (Kessler Psychological Distress Scale, K10) and self-reported overall mental health status; work, lifestyle and family factors correlated with level of psychological distress. Results: The final sample comprised 1124 workers; 93.5% were men, 63% were aged 25–44 years. 311 respondents (28%) had K10 scores indicating high/very high psychological distress, compared with 10.8% for Australia overall. The most frequently reported stressors were missing special events (86%), relationship problems with partners (68%), financial stress (62%), shift rosters (62%), and social isolation (60%). High psychological distress was significantly more likely in workers aged 25–34 years (v ≥ 55 years: odds ratio [OR], 3.2; P = 0.001) and workers on a 2 weeks on/1 week off roster (v 4 weeks on/1 week off: OR, 2.4; P < 0.001). Workers who were very or extremely stressed by their assigned tasks or job (OR, 6.2; P = 0.004), their current relationship (OR, 8.2; P < 0.001), or their financial situation (OR, 6.0; P < 0.001) were significantly more likely to have high/very high K10 scores than those not stressed by these factors. Workers who reported stress related to stigmatisation of mental health problems were at the greatest risk of high/very high psychological distress (v not stressed: OR, 23.5; P < 0.001). Conclusions: Psychological distress is significantly more prevalent in the remote mining and construction workforce than in the overall Australian population. The factors that contribute to mental ill health in these workers need to be addressed, and the stigma associated with mental health problems reduced.

Jennifer Bowers · Johnny Lo · Peta Miller · Daveena Mawren · Brooklyn Jones

Building leadership, governance and evaluation capacity to improve men’s health outcomes

James A Smith · Mick Adams · Jason Bonson

Culturally sensitive integration of medical circumcision could avert adverse effects at traditional male initiation rites

Clement Manineng MB BS, BMSc, · David MacLaren BAppSc, MPH, PhD