Prostate cancer care in the country

There have been enormous advances in prostate cancer care over recent years. However, there are still many challenges when it comes to screening, diagnosing, treating, and managing survivorship of the disease, which affects one-in-six Australian men during their lifetime. For individuals, a prostate cancer diagnosis marks the beginning of a period of concern and uncertainty that will probably stay with them for the rest of their lives. Imagine adding to that situation the need to travel long distances to see doctors with weeks-long waiting lists, the possible need to relocate for treatment, and worrying about paying for all this. It’s not surprising, but it’s still alarming, that prostate cancer outcomes for men living in country Australia are worse than their urban counterparts.

“It all starts with primary health care”

Men living in regional, rural and remote Australia access prostate cancer diagnostic and treatment services less often than their urban counterparts^[1]. They are more likely to have the disease detected during other health procedures rather than preventative screening^[2], present with more advanced prostate cancer at diagnosis^[3] and experience a prominent delay between diagnosis and treatment². All of this contributes to a death rate that is 24% higher in regional areas than the Australian average¹.

“It all starts with primary health care,” says Emma Phillips, Executive Director of Can Assist, an organisation that provides financial assistance and practical support for cancer patients in country NSW. “Our recipients are waiting up to four weeks to see their GP and often need to travel long distances when an appointment is secured. With the prevalence of locums and fly-in-fly-out doctors, continuity of care is compromised for rural residents. As a result, men living in country areas of NSW are less likely to follow recommended regular health screening.”

“Access is the elephant in the room”

Limited health infrastructure, reduced availability of specialist services and workforce shortages are ongoing challenges in regional areas, impacting health outcomes across the board.

“Access is the elephant in the room,” says Prof Jeff Dunn AO, Head of Research at Prostate Cancer Foundation Australia (PCFA). “We need to find new ways of reaching men in regional and rural areas to provide support in a way that suits their individual needs.”

Carroll resident Kevin, 80, was diagnosed with prostate cancer in 2017 after an abnormal PSA level was detected after a checkup. Without his annual screening, Kevin’s prognosis could have been much worse.

“It was a routine test that I went and had done and thank god we found it before it spread,” he says. “I had no symptoms; it was the shock of my life. That’s one of the main questions I get asked by other blokes — ‘what symptoms did you have before you had your blood test’ and I say ‘none!’”

PSA testing is not routine because it is not suitable for all men. Individuals should discuss PSA testing with their doctor.

After his screening, Kevin was referred to a urologist who recommended a biopsy to determine whether he had prostate cancer.

“He said I could have [the biopsy] under anaesthetic, but I’d be waiting over three months to get it, alternatively he said he’d do it in his surgery without anaesthetic and I’d get in pretty quick, so I said we’re going to go that way,” Kevin says. “Had the booking two days later. It wasn’t very pleasant but if I had to, I’d do it again.”

Whether it’s mates, family members or speaking to his local community, Kevin is evangelical in encouraging the blokes he encounters to have a check-up with a doctor. But there are unique barriers that make this process harder than it needs to be.

After he was diagnosed, managing the distance during treatment was the most challenging part for Kevin, who drove hundreds of kilometres for daily radiotherapy sessions in Tamworth.

“Petrol and accommodation costs are the most obvious, but then there is also the extra time taken off work and the forgone income,” Emma says.  

A daily radiotherapy treatment might be accessible on a lunch break for an urban resident but for men in more remote parts of the country, it could involve up to two months off work if they need to relocate for the duration of the treatment. State government subsidies help with covering travel and accommodation costs, but significant gaps remain.

A recent survey of allied health workers based in hospitals across regional NSW found that four out of five cancer patients who travel long distances for treatment required the support of outside charitable assistance to commence, continue or complete treatment.

“That’s truly alarming. We have no doubt that some people choose to skip treatment altogether,” says Emma.  “We have helped many people fill the gap. Recently, one patient told us that without our support he would have had to sell his home to access treatment.”

“These impacts are often amplified”

Grappling with prostate cancer is already a stressful experience and barriers to satisfactory care can cause added distress.

“All men diagnosed with prostate cancer face a 70 per cent increased risk of suicide death, which is a significant concern,” Dunn says.

Since the launch of PCFA’s nationwide Telenursing service in 2021, they’ve found one in four callers from rural and remote areas have severe distress, compared to just six per cent of men who call from metro and major regional centres.

Factors that could contribute to this disproportionately higher burden of distress in regional and remote areas include the geographic distance to treatment, lack of access to locally based psychosocial support and other external stressors like financial hardship and employment concerns.

A study of men’s help-seeking in the first year after diagnosis found that 82% of men reported unmet supportive care needs relating to sexual function, mental health, and health system and information issues.

“For men in rural and remote areas, these impacts are often amplified, and although prostate cancer survival has increased over time, serious socio-economic and geographic inequalities persist, with disadvantaged prostate cancer patients subject to lower survival than those in higher socio-economic groups,” Dunn says.

What’s next?

Significant investment, reform and innovation are necessary for improving the lives of men in regional, rural and remote Australia with prostate cancer.

“As far as diagnosis and treatment goes, some of the best work being done in this space could help to bring next-generation imaging modalities to men in regional centres, although we need to see much stronger public investment in research and technologies to help accelerate research projects in this area,” Dunn says.

A review of the current guidelines for PSA testing is also a critical step. “A new set of guidelines may well highlight the particular risks and barriers confronting country men, and help us to tackle the issues head-on,” Dunn says.

Can Assist supports Wellness Day, which encourages workplaces and communities to prioritise their wellbeing and get a health check that they may have been avoiding, whether that's a PSA test or a skin check. Find more information and get involved here.