For men without a prostate cancer diagnosis or symptoms that might indicate prostate cancer, how many years after the start of PSA testing is the benefit of PSA testing apparent? (PICOi question 5)
Guidelines developed in partnership with
Prostate Cancer Foundation of Australia and Cancer Council Australia PSA Testing Guidelines Expert Advisory Panel. Clinical practice guidelines PSA Testing and Early Management of Test-Detected Prostate Cancer. Sydney: Cancer Council Australia. [Version URL: http://wiki.cancer.org.au/australiawiki/index.php?oldid=142395, cited 2017 Nov 24]. Available from: http://wiki.cancer.org.au/australia/Guidelines:PSA_Testing/PSA_Testing_and_life_expectancy.
National Health and Medical Research Council
In approving the guidelines (recommendations), NHMRC considers that they meet the NHMRC standard for clinical practice guidelines. This approval is valid for a period of five years. NHMRC is satisfied that the guidelines (recommendations) are systematically derived, based on the identification and synthesis of the best available scientific evidence, and developed for health professionals practising in an Australian health care setting.This publication reflects the views of the authors and not necessarily the views of the Australian Government.
- 1 Background
- 2 Evidence
- 3 Evidence summary and recommendations
- 4 Footnote
- 5 References
- 6 Discussion
There is an inevitable delay between application of a test to detect cancer early and any reduction in cancer mortality a person or group of people may experience as result of the test. Therefore, testing people with only a short life expectancy may offer no benefit against which to balance the cost or inconvenience of the test or any short-term harm that may flow from it (e.g. consequences of a false positive test, or unnecessary treatment for a cancer detected that would never have manifest clinically during the person’s lifetime).
Time period for the benefit of PSA testing to become apparent
The ERSPC and data from two of its component study centres (Rotterdam and Gøteborg) provided evidence on the time from first having a PSA test to the first appearance of a mortality reduction consequent on testing. This evidence was judged to be at moderate risk of bias. The search strategy, inclusion and exclusion criteria, and quality assessment are described in detail in the Technical report.
The ERSPC found little evidence that PSA testing at 2 or 4 yearly intervals reduced mortality before 7 years after testing began (RR 0.92; 95% CI 0.73–1.18). Thereafter, there was evidence of reduction in mortality at 8–9 years after testing began (RR 0.74; 95% CI 0.55–0.99), which was stronger again at 10–11 years after testing began (RR 0.62; 0.45–0.85). The ERSPC and its Rotterdam and Gøteborg components also published plots of cumulative hazard of death from prostate cancer in screening and control arms by time since screening began (Nelson–Aalen method). Reading from these plots, it was estimated that divergence of the cumulative hazards was first evident at 7 years in ERSPC men aged 55–69 years, Gøteborg men aged 50–69 years and Rotterdam men aged 55–74 years, and at 6 years in Rotterdam men aged 55–69 years.
Evidence from the Gøteborg centre, with wider confidence intervals and higher risk of bias, suggests that the lower mortality from prostate cancer in the intervention group was no longer evident 9–12 years after testing ended.
Likelihood that a man will survive long enough to benefit from PSA testing
The likelihood that an Australian of a given age will live for a certain number of years can readily be determined from the Australian Life Tables published by the Australian Government Actuaryii. For example, the percentage of men of a given age who will live for another 7 years, calculated from the Australian Life Tables 2010-12 – Males,56 is as shown in Figure 2.3. Reading from this Figure, for example, 50% of men aged about 83 years can be expected to live more than another seven years.
Figure 2.3. Percentage of Australian men of a given age remaining alive after 7 years from ages 50 to 100
Source: Australian Life Tables 2010-12 – Males
The Australian Life Tables 2010-12 are based on Census data and therefore represent the mortality of men and women in average health for their age. Many older men and women have a number of co-morbidities, which can have a significant impact on life expectancy. Hence, ideally the mortality data would be stratified by health status to enable more accurate advice to be given to a man about whether he is likely to live long enough to benefit from PSA testing. That is beyond the scope of this guideline. However, development of an online calculator tool based on Australian data, and which does take account of health status, is underway.
Evidence summary and recommendations
|For men without a prostate cancer diagnosis or symptoms that might indicate prostate cancer, a reduction in the risk of death from prostate cancer was apparent at 6–7 years after the start of PSA testing.||II||, , , |
|Since any mortality benefit from early diagnosis of prostate cancer due to PSA testing is not seen within less than 6–7 years from testing, PSA testing is not recommended for men who are unlikely to live another 7 years.||C|
When discussing the benefits and harms of PSA testing with older men or those with a potentially fatal chronic illness, explain each of the following:
The percentage of men of a given age, and average health status for their age who are expected to live for another 7 years is as shown in the table below.
Health system implications of these recommendations
Implementation of the recommendation would require clinicians to consider life expectancy whenever they offer a PSA test. Current Australian guidelines for disease prevention in primary care advise that men with a life expectancy of less than 10 years are at reduced risk of dying from prostate cancer. Reducing the estimate of the life expectancy at which a PSA test may have benefit from 10 years to 7 years may increase the number of men tested. However, it is not possible to predict whether there would be a net increase, reduction or no change in the number of men tested, because it not known whether all clinicians routinely discuss life expectancy when providing information about the risks and potential benefits of PSA testing, or the accuracy of life expectancy estimates in practice.
Implementation of this recommendation would have no significant resource implications.
Barriers to implementation
No barriers to the implementation of this recommendation are foreseen.
i Clinical questions were translated into the PICO framework: population, intervention (or exposure), comparator and outcome (see Appendix 3).
ii The latest tables, the Australian Life Tables 2010-12, are based on the mortality of male and female Australians over the three calendar years centred on the 2011 Census of Population and Housing.
- Schröder FH, Hugosson J, Roobol MJ, Tammela TL, Ciatto S, Nelen V, et al. Prostate-cancer mortality at 11 years of follow-up. N Engl J Med 2012 Mar 15;366(11):981-90 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22417251.
- Roobol MJ, Kranse R, Bangma CH, van Leenders AG, Blijenberg BG, van Schaik RH, et al. Screening for prostate cancer: results of the rotterdam section of the European randomized study of screening for prostate cancer. Eur Urol 2013 Oct;64(4):530-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23759326.
- Hugosson J, Carlsson S, Aus G, Bergdahl S, Khatami A, Lodding P, et al. Mortality results from the Göteborg randomised population-based prostate-cancer screening trial. Lancet Oncol 2010 Aug;11(8):725-32 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20598634.
- Grenabo Bergdahl A, Holmberg E, Moss S, Hugosson J. Incidence of prostate cancer after termination of screening in a population-based randomised screening trial. Eur Urol 2013 Nov;64(5):703-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23721957.
- Commonwealth of Australia. Australian Life Tables 2010-2012.; 2014 [cited 2014] Available from: Available from: http://www.aga.gov.au/publications/life_table_2010-12/default.asp.
- Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice. 8th ed. Melbourne: RACGP; 2012.