Men's health

CorrectionError in calculating costs of screening: In “Risk assessment to guide prostate cancer screening decisions: a cost-effectiveness analysis” in the 3 June 2013 issue of the Journal (Med J Aust 2013; 198: 546-550), there was an error in the way screening costs were calculated. These corrections do not alter the study conclusions. The corrected figures are in bold as follows. Results section of the abstract (page 546): “The ...

Andrew J Martin PhD · Sarah J Lord MB BS, MS(Epi) · Hannah E Verry BEcon · Martin R Stockler MB BS, MSc, FRACP · Jon D Emery MB BCh, MA, DPhil

To the Editor: We are concerned by conclusions drawn by Del Mar and colleagues,1 in stating that because some autopsy studies have claimed more than 50% prevalence of latent prostate cancer in men aged over 60 years, this could be considered normal, and that these latent cancers result in a high level of overdiagnosis of prostate cancer. The study cited was conducted at Wayne State University, ...

Paul R McKenzie · Brett Delahunt · James G Kench

To the Editor: Recent articles in the Journal evaluating the evidence on screening for early-stage prostate cancer1,2 failed to mention one of the most important pieces of evidence ever published on the treatment of prostate cancer.3 This randomised controlled trial (RCT) showed that, compared with observation, radical prostatectomy did not significantly reduce all-cause or prostate cancer mortality over at least 12 years among men with clinically ...

Ian E Haines

To the Editor: We read with interest Del Mar and colleagues’ “re-examination” of the evidence for prostate cancer screening.1 Rather than presenting a balanced view, they have pursued a lopsided and flawed review of the data. First, they have given equal weighting to the results of the screening trials from Europe (ERSPC [European Randomized Study of Screening for Prostate Cancer]) and North America (PLCO [Prostate, Lung, ...

Nathan Lawrentschuk · Declan G Murphy · Anthony J Costello

In reply: We wish to make some comments in response to Haines’s point that the PIVOT (Prostate Cancer Intervention Versus Observation Trial) failed to show any benefit from radical prostatectomy (RP) over surveillance. First, in the PIVOT, a benefit of RP in terms of reduced all-cause mortality was suggested in men with a prostate-specific antigen (PSA) level > 10 ng/mL and in men with intermediate- and high-risk prostate ...

Jonas Hugosson · Sigrid V Carlsson

In reply: We thank Lawrentschuk and colleagues for the critical response. We would like to respond to several wrong assertions: We did not give equal weighting to the results of the ERSPC (European Randomized Study of Screening for Prostate Cancer) and the PLCO (Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial). Standard meta-analysis practice is to weight studies by the inverse variances of their effect estimates.1 ...

Chris B Del Mar*

Objectives: To apply the most recent evidence from randomised trials of prostate-specific antigen (PSA) screening and explore the potential value of risk assessments to guide the use of PSA screening in practice.Design: A decision model that incorporated a Markov process was developed in 2012 to estimate the net benefit and cost of PSA screening versus no screening as a function of baseline ...

Andrew J Martin PhD · Sarah J Lord MB BS, MS(Epi) · Hannah E Verry BEcon · Martin R Stockler MB BS, MSc, FRACP · Jon D Emery MB BCh, MA, DPhil

A study of help-seeking behaviours, reproductive disorders and rates of testing for prostate problems in Aboriginal and Torres Strait Islander men from urban, rural and remote communities in the Northern Territory and Queensland.

Michael J Adams BSW, MA, PhD · Veronica R Collins BSc, MSc(Epidemiol), PhD · Michael P Dunne BA(Hons), PhD · David M de Kretser MB BS, MD, FRACP · Carol A Holden BSc(Hons), PhD, MPH

Extreme rates of gonorrhoea in remote areas must be reducedIn this issue of the Journal, there are two important articles highlighting the disadvantages experienced by Indigenous Australians, and offering important practical suggestions for improving health care.1,2 The article by Graham and colleagues analyses the notification rates for chlamydia and gonorrhoea in Australia by Indigenous status.1 Their findings are stunning. Compared with non-Indigenous Australians, Indigenous Australians have ...

Christopher K Fairley FRACP, PhD, FACSHP · Jane S Hocking MPH, MHlthSc, PhD

Objective: To describe patterns of testosterone prescribing in Australia over the past two decades by state or territory and by product type.Design and setting: Observational analysis of testosterone prescribing data obtained from two independent data sources — the Pharmaceutical Benefits Scheme (PBS) and IMS, a source of commercial pharmaceutical sales data.Main ...

David J Handelsman MB BS, FRACP, PhD

New data from the Health in Men Study raise questions about the role of testosterone supplementation in ageing men Ageing of the “baby boomer” generation foreshadows a future shaped by demographic change, with increasing numbers of older Australians. The large, longitudinal Western Australian Health in Men Study (HIMS) is therefore timely, as it examines the endocrinology of male ageing and predictors of health in community-dwelling older men.1,2 As part of HIMS, my colleagues and I surveyed 3274 men aged 75–95 years in 2008–2009 using a questionnaire that included items on sexual activity.3 Of 2930 men who reported on the importance they attached to sex, 48.8% considered it important, and of the 2783 men who provided data on sexual activity, 30.8% had at least one sexual encounter (defined as any mutually voluntary activity with another person that involves sexual contact, whether or not intercourse or orgasm occurs4) in the previous 12 months.3 Of these older sexually active men, 56.5% were satisfied with the frequency of sex, while 43.0% would have preferred sex more frequently.3 These findings indicate that many older Australian men consider sexual activity important and desirable. In HIMS, factors that predicted reduced sexual activity were increasing age, osteoporosis, prostate cancer, diabetes, antidepressant use, β-blocker use, and partner’s lack of interest or physical limitations.3 Living with a partner and having a non-English-speaking background were associated with increased sexual activity. Interestingly, a 1 SD increase in testosterone level, measured in blood samples collected in 2001–2004, was associated with a 20% increased likelihood of being sexually active in 2008–2009. Therefore, while older men with lower testosterone levels are likely to report symptoms such as reduced frequency of sexual thoughts and erectile difficulties,5 higher testosterone levels predict sexual activity several years into the future. This raises the question of whether giving exogenous testosterone to induce a comparable increase in circulating total testosterone levels (+ 5.6 nmol/L) would increase the frequency of sexual activity for older men. Epidemiological studies such as HIMS show that men with testosterone levels in the low-normal range have poorer health outcomes; for example, those with testosterone levels in the lowest quartile (< 11.7 nmol/L) have increased risk of stroke or transient ischaemic attack.6 Lower testosterone levels are associated with mortality in older men.7 Studies of testosterone therapy in older men show favourable effects on body composition, with increased lean mass and bone mineral density and, to an extent, improved muscle strength.8 However, there is no evidence as yet that testosterone therapy reduces cardiovascular events or mortality, or that it increases sexual activity in older men. In fact, administering higher doses of testosterone to older men with limited mobility might result in an excess of adverse cardiovascular events.9 More data are needed to help design optimal studies to clarify the role of testosterone supplementation in ageing men. In HIMS, the mean serum total testosterone level in 3638 men aged 70–89 years was 15.4 nmol/L (reference range, 8–35 nmol/L), and only a minority would have been classified as having unequivocally low testosterone levels.1 Uncertainty remains around the extent to which lower testosterone levels reflect underlying comorbidity; appropriate testosterone thresholds for the diagnosis of androgen deficiency in older men; and effects of testosterone therapy on cardiovascular risk.8 The current Testosterone Trial (ClinicalTrials.gov identifier NCT00799617) in the United States, due for completion in 2015, is recruiting older men with lower testosterone levels and will examine the effect of transdermal testosterone gel on end points of walking speed, sexual activity, vitality, memory and anaemia correction. So while the question of whether testosterone therapy might protect against cardiovascular events remains unresolved, its impact on sexual activity in the setting of a randomised controlled trial might not be known for another 4 years. Under these circumstances, the clinical approach to ageing men with symptoms of testosterone deficiency must be prudent, taking both known risks and potential benefits into account.8 Testosterone supplementation could be considered in men who are clearly hypogonadal. Symptoms of androgen deficiency should be assessed, and the diagnosis based on at least two unequivocally low early-morning testosterone levels, preferably assayed using a mass spectrometry-based methodology.10 Men should be counselled as to the risks and benefits of testosterone therapy, and treatment should be accompanied by safety monitoring, including prostate evaluation and monitoring of prostate-specific antigen levels and haematocrit. The anticipated effect of testosterone therapy would be to increase libido, and this should be included in the discussion of benefit and risk. While higher testosterone levels are associated with sexual activity in older men, non-hormonal factors are also important. HIMS found that increasing age predicted declining sexual activity; after adjusting for this and other covariates, men were four times more likely to be sexually active if they were living with a partner.3 Conversely, they were much less likely to be sexually active if their partner lacked interest in sex or had physical limitations. Medical comorbidities including diabetes and use of antidepressants were also associated with reduced likelihood of being sexually active. Therefore, social and medical factors are key determinants of whether ageing men remain sexually active. The increasing numbers of men transitioning from middle to older age should be encouraged to maintain their personal health and the health of their relationships to maximise their chances of having sex in future years.

Bu B Yeap MB BS, FRACP, PhD

Coordinated action is necessary to improve the health of all Australian males The fourth Andrology Australia Forum on men’s health was held in Sydney on 4–6 June 2010, with about 70 researchers, policymakers and health professionals in attendance. The forum theme was “Tackling the inequities of men’s health”, and it provided the opportunity to consider one of the six priority areas of the National Male Health Policy — “Health equity between population groups of males”.1 The presentations and discussions highlighted areas for further consideration in policy implementation, while acknowledging the complexity of addressing health inequities through policy initiatives. Male health policyThe Honourable Warren Snowdon, MP (former Minister for Indigenous Health, Rural and Regional Health and Regional Services Delivery), gave a keynote address on the first Australian National Male Health Policy.1 The Minister described the policy process, highlighting his involvement and drawing on his personal experience working with Indigenous communities, which ensured that a broad range of male health issues through the lifespan were included. Dr Noel Richardson (Director, Centre for Men’s Health, Institute of Technology Carlow, Ireland) followed, giving an account of the Irish experience in formulating a national men’s health policy.2 His account provided a direct contrast between the two policy processes. While both policies were underpinned by extensive community consultation, the Irish policy benefited from a strong evidence base commissioned by the government specifically for the policy, whereas the Australian policy was driven by grassroots men’s groups and guided by the limited available empirical research. This led to different guiding principles: Dr Richardson described the Irish policy as drawing on a “gender-mainstreaming” framework, in which gender is acknowledged as a key determinant of health. It also recognises the interaction of masculinities with social and economic factors in influencing men’s health, compared with the approach using broader social determinants in guiding the Australian policy. The Minister acknowledged that coordinated action by the whole workforce was necessary to drive change. He also emphasised the need to embed the policy into government frameworks to withstand possible changes in government priorities. However, the broader structural change through which health inequities could be addressed was not clearly articulated. An important lesson from the Irish experience was the value of the policy itself in facilitating work across government sectors, not just health services, with men’s health now seen as a priority area. Importantly, both speakers acknowledged the impact of recent economic events on the policies, with the Minister highlighting that in such financial circumstances it was important to direct resources to areas that can further policy objectives in the long term. Finally, forum delegates welcomed the Minister’s announcement that a male health policy reference group would be established. This would be to provide expert advice and assistance with the implementation of policy action areas, such as the proposed National Longitudinal Study on Male Health. This announcement partially reflected one of the fundamental lessons learned from the Irish experience: the need for good governance and accountability. However, it did not go as far as the requirement by the Irish government for annual progress reporting. While policy formulation reflected different mechanisms, both acknowledged the need for an evaluation and monitoring strategy to be established from the outset. Research data, evidence and policySeveral speakers highlighted the need for good data to underpin policy development and implementation. Lisa Thompson and Sally Bullock (data analysts, Australian Institute of Health and Welfare) reported data showing the poorer health status of men living in rural and remote areas. In particular, the data showed higher rates of chronic diseases that are partly due to lower socioeconomic status, but other factors remain to be elucidated.3 More focused data and policy analysis for groups with poor health and/or social isolation were called for, using cross-sectional health surveys, data linkage and longitudinal studies. Professor Sally Redman (Chief Executive Officer, The Sax Institute) expanded on the value of longitudinal studies in providing high-quality evidence for policy questions. Using the 45 and Up Study as an example, Professor Redman highlighted how longitudinal studies can be used by researchers and policymakers. “Add-on” studies and data linkage can be used to answer questions arising over time, thus “future proofing” the significant investment necessary to conduct a longitudinal study. Acknowledging the time lag between evidence and policy, Professor Redman called for better ways to provide robust evidence to policymakers. James Smith (Discipline of Public Health, University of Adelaide) underscored this point by showing how evidence (in this case, qualitative evidence) can debunk myths promulgated by opinion rather than empirical research. Mr Smith argued for closing the biomedical–social and qualitative–quantitative research gaps to answer the important questions in men’s health. He coupled this with an emphasis on translating research into policy and practice. Professor Gavin Turrell (Principal Research Fellow, School of Public Health, Queensland University of Technology) discussed the strong association between socioeconomic status and male health. He emphasised the need for a whole-of-government and whole-of-society approach to tackle socioeconomic inequities. In discussing policy implementation, Professor Turrell argued that interventions should be focused on environments as well as individuals, and occur across the lifespan, requiring an alignment of public policy and health policy. Improved monitoring and surveillance systems could address some of the gaps in Australian men’s health data, allowing proper evaluation of interventions designed to address socioeconomic inequities. On a different theme, Associate Professor Doug Lording (Endocrinologist, Cabrini Medical Centre) highlighted emerging areas that require better policy, such as purchasing unsafe or ineffective medications from the internet or other unregulated markets. Improvements in health literacy and health promotion, as well as better regulation, are needed to meet the needs of those who are vulnerable to health practices that could be described as predatory. Specific groups of men at riskUnderstanding the impact of cultural and social contexts on men’s health, highlighted in several presentations, generated lively discussion. Dr Mick Adams (Director, Fineline Consultancy) set some challenges for redressing past (and present) wrongs that have had significant impacts on Indigenous male health. He emphasised the importance of reconstructing male empowerment to improve quality of life, health status and spiritual wellbeing. Referring to the United States Office of Indian Men’s Health, Dr Adams called for similar initiatives from our government to turn policy statements into real action. On the theme of empowerment, Jack Bulman (Chief Executive Officer, Mibbinbah) described the Mibbinbah (“Men’s Place”) model of health promotion. The focus here is on creating safe spaces for Aboriginal and Torres Strait Islander males where they can acquire skills to take back to work with men in local communities. Mibbinbah’s success lies in its capacity to network with local Indigenous organisations and broader community health organisations. Pino Migliorino (Chair, Federation of Ethnic Communities’ Councils of Australia) highlighted the significant health literacy issues for men, particularly older men, from culturally and linguistically diverse (CALD) backgrounds. He emphasised the importance of bringing ethno-specific organisations on board as partners with mainstream services, to address barriers to accessing health services and to aid in understanding health contexts of men from CALD backgrounds. Gordon Gregory (Executive Director, National Rural Health Alliance) stressed that access issues are also crucial for men living in rural and remote areas, irrespective of whether “rural attitudes” such as “valuing independence” still exist. There are some obvious system barriers, such as a lack of general practitioners in rural areas, that require modern solutions, such as greater use of information technologies. Professor Gary Dowsett (Acting Director, Australian Research Centre in Sex, Health and Society, La Trobe University) gave some background on the gay men’s health movement, arguing that gay men have specific health needs that should be kept on the policy agenda. Although comprehensive data are lacking, Professor Dowsett pointed to eating disorders, drug use and mental health disorders as being common in this group, in addition to sexual health issues. While noting the failure of the current policy to adequately acknowledge gay men’s health needs, he called for better data collection tools to answer the most relevant questions about gay men’s health, requiring a rethinking of traditional health data categories. Workforce capacityThere was general agreement that addressing inequities in men’s health requires a multisector focus on workforce capacity. Dr Michael Wright (Research Fellow, Telethon Institute for Child Health Research) spoke about the Aboriginal and Torres Strait Islander male researcher network. Building Indigenous research capacity to better deliver evidence and engage with policymakers will be integral to improving Aboriginal and Torres Strait Islander male health. Dr Mark Wenitong (Senior Medical Officer, Apunipima Cape York Health Council) spoke about increasing both the capacity and the quality of the Indigenous health workforce. He stressed the cultural importance of male health workers and pointed out that there is a current shortage of male nurses, and Aboriginal and allied health workers. Policy levers such as the Aboriginal and Torres Strait Islander Health Workforce Working Group,4 and programs such as the Indigenous health curriculum framework for medical schools5 and the Andrology Australia Aboriginal and Torres Strait Islander Male Health Module need further investment from government. Dr Wenitong argued for improved pathways and structural support to enable Aboriginal and Torres Strait Islander people to progress through health workforce education and training. Peter Strange (Nurse Practitioner, Bendigo Community Health Services) highlighted the current lack of men’s health education in undergraduate and postgraduate nursing and allied health curricula, and Professor Rob McLachlan (Director, Andrology Australia) spoke about the lack of men’s health education in the medical undergraduate curriculum. These deficiencies flow through to a lack of men’s health specialist services and local programs. Audience discussion reflected on the critical need for more focused training across these domains, reinforcing that men’s health could be incorporated as a core education component and/or specific postgraduate training to build defined men’s health career pathways. Men’s health programsDescriptive accounts of programs designed to address male health disparities through better access and support (Box) prompted discussion of the need for program evaluation. Although the workplace is seen as a potentially successful forum for men’s health promotion, for example with high attendances recorded at WorkSafe Victoria’s workplace health checks, evaluations of the effectiveness of such programs can be limited due to privacy and other issues. ConclusionThe forum provided a timely opportunity to reflect on the National Male Health Policy and its specific aim to address health disparities between population subgroups of men. The forum only provided a snapshot of current men’s health initiatives, and it became clear that a number of areas still require policy focus. These areas included the need for explicit linkage, coordination and cooperation across service provision, research, policy and practice. Policy action areas have been defined, but opportunity exists to reflect on the international, national, regional, local and individual experience to bring coordinated action to improve the health of all Australian males. Examples of men’s health promotion program Bringing health into the workplace Rachel Gualano, Acting Director, WorkHealth, WorkSafe Victoria WorkHealth program health checks for diabetes and cardiovascular disease risk factors done in the workplace Building workforce capacity in community health (in men’s health) Peter Strange, Nurse Practitioner (Men’s Health), Bendigo Community Health Services, Victoria Rural men’s health promotion model: community events for men, male-friendly health clinics and workplace programs, such as health assessments for men in sheep saleyards Strengthening networks through peer support Bill McHugh, Past Chair, Support and Advocacy Committee, Prostate Cancer Foundation of Australia; Brisbane Prostate Cancer Support Network, Queensland Network of 99 prostate cancer support groups with three levels of organisation: individual peer support, state chapters, and the National Support and Advocacy Committee

Veronica R Collins PhD · Robert I McLachlan MB BS, FRACP, PhD · Carol A Holden PhD

Objective: To determine the prevalence and diagnosis rates of Klinefelter syndrome (KS) in Victoria, Australia, and compare these to previous international findings.Design, setting and participants: A Victorian population-based descriptive study of all cytogenetic examinations resulting in a diagnosis of KS, including prenatal diagnoses from 1986 to 2006 and postnatal diagnoses from 1991 to 2006.Main outcome measures: Birth prevalence and diagnosis rates of KS.Results: The birth prevalence of KS in Victoria is estimated to be 223 per 100 000 males (95% CI, 195–254), with about 50% of cases remaining undiagnosed.Conclusions: KS may be occurring more frequently than has been reported previously, yet many cases remain undiagnosed. Our results highlight the need for increased awareness leading to timely detection.

Amy S Herlihy BSc, GradDipGenCounsel · Jane L Halliday BSc(Hons), PhD · Megan L Cock BSc(Hons), PhD · Robert I McLachlan MB BS, PhD

To the Editor: Flitcroft and colleagues’ discussion of the National Bowel Cancer Screening Program provides a useful reminder of how political, institutional and financial issues can affect evidence-based policy.1 Bowel cancer is second to prostate cancer as the biggest cause of cancer death in Australian men, and men are more likely than women to be diagnosed with bowel cancer. There are no indications, however, that the screening program has sought to engage men as a target group. Men and women think about and act on their health in different ways and respond differently to messages, sources of information and modes of information delivery.2 Men are less likely than women to undergo preventive screening and are more likely to seek treatment at a later stage in a disease. A report for the Australian Government noted that, before receiving the Bowel Cancer Screening Pilot Program material, men were less likely to have been aware of preventive or pre-emptive behaviours “unless their GP had actually raised the subject with them, or a close friend had suffered, bringing the issue to a more personal level”.3 Further evidence indicated that fewer than one-third of men participated in the screening from mid 2006 to mid 2007, despite men aged 55 and 65 years being more likely than women to return positive results; among men aged 55 years, only 28% chose to participate.4 Participation rates during the 2-year screening period ending August 2008 were estimated to be 39.2% for men and 46.7% for women.5 Despite the considerable evidence that the “doing of health” is a highly sex-dependent activity, a population-based, “one size fits all” approach appears to have been adopted. Adding further insult to injury, men were blamed for their lower participation rate and for failing to understand “that screening for cancer saves lives”.6 A disappointing response to a free breast cancer screening initiative, on the other hand, prompted an investigation into the relationship between the wording of the screening invitation letter and the level of screening attendance.7 With around one in 19 men predicted to develop bowel cancer before the age of 75 years, men’s under-representation in bowel cancer screening is a serious problem. There is a need for more attention to be given to men’s attitudes and beliefs about risk and prevention, with a view to developing specific approaches to increase men’s participation in screening.8 It should not be too much to expect that Australia’s first National Men’s Health Policy, and an updated National Women’s Health Policy, will result in sex being taken into account in the design and implementation of national health initiatives.

Margo H Saunders · Anita Peerson

To the Editor: Flitcroft and colleagues’ historical report of bowel cancer screening in Australia is helpful to those new to this internationally accepted life-saving practice.1 One inaccuracy needs correcting. Lung cancer is the leading cause of cancer death in Australia — not prostate or breast cancer. Flitcroft et al appear to have quoted the Australian Institute of Health and Welfare data for new diagnoses, not cancer deaths.2 This error reflects the general lack of community focus or interest in the more than 7000 Australians who die each year from smoking-related lung cancer.3 An update is also warranted. Since submission of their article, once-only flexible sigmoidoscopy screening has joined faecal occult blood test (FOBT) screening in having randomised controlled trial evidence. Results of a recent British study point to the necessity of looking for this occult disease with flexible colorectal endoscopy.4 The study showed a massive 43% reduction in colorectal cancer mortality and a 50% reduction in incidence of invasive rectal cancer, owing to early flexible sigmoidoscopic diagnosis of colonic polyposis followed by polypectomy performed at subsequent colonoscopy. These techniques save thousands of lives worldwide each year. Flitcroft et al state that “A staged roll-out is a sensible approach”, but many of us who perform colonoscopic polypectomies on a weekly basis strongly disagree. Which is better — to be on a waiting list for a colonoscopy with a positive FOBT result, or to be ignorant of the possibility of a growing cancer in the colon? It is time to give people the opportunity of FOBT with or without further investigations. Flitcroft et al rightly point out that the National Health and Medical Research Council recommended that we should have at least biennial FOBT screening for individuals over 50 years of age.5 Australians have been very tardy in terms of adopting this recommendation. We don’t need an “age-specific cost-effectiveness analysis”. The argument should be about introducing flexible sigmoidoscopy. Like Semmelweis and hand washing back in 1847, history will judge our current generation harshly for ignoring the original life-saving FOBT research that was published in 19936 and allowing thousands of Australians to die unnecessarily from bowel cancer since then. It is time for us to take our heads out of the sand and introduce a proper national bowel cancer screening program. Thank you to Flitcroft and colleagues for helping us take another step in this direction.

Guy R Hingston