PSA Testing

Prostate cancer (PC) is the most common malignancy diagnosed in men and the second most common cause of cancer deaths in men1.  As such, the early diagnosis of PC by use of the Prostate-specific Antigen (PSA) blood test has the potential to significantly impact on this significant health problem. However, since PC increases with advancing age and has a long and often highly variable natural history, the potential benefits of PSA-testing need to be weighed against potential harms of detecting and treating so-called “insignificant” cancers. This has led to a long-standing controversy that has made it difficult to provide patients with rational advice. The difficulties have been compounded by conflicting positions taken by various professional bodies. Nonetheless, PSA-testing has increased dramatically over time2 and the decision on how to advise men remains a difficult one for general practitioners (GPs)3.

In January 2016, the Prostate Cancer Foundation of Australia and the Cancer Council Australia released clinical practice guidelines on PSA-testing4. These guidelines are unique on the world stage in having been developed by consensus by an expert advisory group involving all involved groups: general practitioners, urologists, epidemiologists, radiation oncologists, medical oncologists, allied health professionals and consumers5. The guidelines have now been endorsed by all major professional bodies, including the Urological Society of Australia and New Zealand (USANZ)6, the Royal Australian College of General Practice7 and the National Health and Medical Research Council. It is hoped that adoption of these guidelines will maximise the potential benefits of PSA-testing while minimising potential harms.

The guidelines will be updated every three years, and can be accessed in full online8. The key recommendations from the guidelines are summarised below (comments in italics not based on guidelines):

  • Population-wide screening is not recommended, but men should be offered evidence-based decision support on whether to have PSA-testing.
  • PSA-Testing age and frequency
    • Men at average risk: 2-yearly from age 50 to 69
    • Men with one 1st-degree relative with PC: 2-yearly from age 45 to 69
    • Men with three or more 1st degree relative with PC: 2-yearly from age 40 to 69
  • Advise against PSA-testing
    • Age <50 (unless in high-risk groups)
    • Age >70
    • Life-expectancy <7years
  • Rectal examination not recommended as routine for PSA-testing (although USANZ recommends GPs who are confident in their examination skills continue to do so, since some PC presents with normal PSA levels6)
  • Abnormal PSA-tests (>3.0 according to the guidelines – different laboratories may provide differing cut-off values, which may be age-specific) should be repeated, with a free-to-total (F:T) PSA measurement at the same time.
  • Refer for urological assessment and consideration of prostate biopsy if PSA level >5.5 or F:T ratio <25%
  • MRI-scanning may be useful after initial negative biopsy to determine need for repeat biopsy (but is not currently proven for initial diagnostic use. USANZ recommends its use for restricted indications by PC specialists, and not in primary care9).

The guidelines also make recommendations on appropriate action to further investigate and manage abnormal PSA results, newly diagnosed prostate cancer and negative biopsies. Again, the aim of these recommendations are to minimise risks associated with PSA-testing, while enabling the early diagnosis and effective treatment of men with aggressive PC.

References:
1. AIHW 2014. Cancer in Australia: an overview 2014. Cancer series no. 90. Cat. no. CAN 88. Canberra: AIHW.
2. Ranasinghe WK, Kim SP, Lawrentschuk N, Sengupta S, Hounsome L, Barber J, Jones R, Davis P, Bolton D, Persad R. Population-based analysis of prostate-specific antigen (PSA) screening in younger men ( 3. Mahar P, Corcoran N, Ludlow K and Sengupta S, 2010. Prostate specific antigen: useful screening tool or potential liability? Aust Fam Physician, 39: 598-600
4. Prostate Cancer Foundation of Australia and Cancer Council Australia PSA Testing Guidelines Expert Advisory Panel. Draft clinical practice guidelines for PSA testing and early management of test-detected prostate cancer. Prostate Cancer Foundation of Australia and Cancer Council Australia, Sydney (2016).
5. http://www.prostate.org.au/awareness/for-healthcare-professionals/clinical-practice-guidelines-on-psa-testing/finalised-clinical-guidelines-for-prostate-test-launched-today/
6. http://www.usanz.org.au/psa-guidelines/
7. http://www.racgp.org.au/yourracgp/news/media-releases/racgp-endorses-new-guidelines-against-prostate-cancer-screening/
8. http://wiki.cancer.org.au/australia/Guidelines:PSA_Testing
9. http://www.usanz.org.au/prostate-mri-statement/


Shomik SenguptaAUTHOR | A/Prof Shomik Sengupta
A/Prof Sengupta is a urologist with a uro-oncology interest. He is involved in numerous clinical trials, including the ANZUP Cancer Trials Group, and leads the GU Oncology Advisory Group within the Urological Society of Australia and New Zealand.
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