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=122818, cited 2017 Nov 20]. Available from: http://wiki.cancer.org.au/australia/Guidelines:PSA_Testing/Summary.
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.
Prostate cancer is the second-most commonly diagnosed cancer in Australian men (after skin cancer), and is the second most common cause of cancer death in Australian men (after lung cancer). The illness and disability caused by prostate cancer also has a big effect on the lives of Australian men and their families.
Tests for early prostate cancer in men without symptoms
The two tests that are commonly used to find prostate cancers early are a blood test to measure the level of prostate-specific antigen (PSA), and digital rectal examination (when a doctor examines the prostate by feeling it with a finger inserted in the rectum). Neither of these tests is very accurate. A man’s PSA test result can be abnormal when he does not have prostate cancer, or his PSA result may be normal even though he has prostate cancer.
For men without symptoms of prostate cancer, choosing whether or not to have a test to find prostate cancer early is often a hard decision. This is because it is hard to tell whether a cancer found after having a test will spread or not, and whether it will cause problems during the man’s lifetime. Thus men will need to decide whether to have their prostate removed (radical prostatectomy), or treated with radiation (radiotherapy), without knowing for sure the treatment is really necessary. Because of this uncertainty and because the treatment can cause problems getting an erection, bladder problems and bowel problems, doctors should fully explain the benefits and harms of testing, using booklets, charts or other tools designed to help men make the decision whether or not to have a test.
For those who decide to have prostate cancer tests, the general recommendation is to have a PSA blood test every 2 years from age 50 to age 69. For men whose risk of prostate cancer is higher than average (e.g. with a brother diagnosed with prostate cancer), regular testing can start earlier. PSA testing is not recommended for a man who is unlikely to live for another 7 years (e.g. a man who already has another serious illness), because PSA testing can generally only prevent deaths due to prostate cancer that would have occurred more than 7 years into the future. It is not possible to tell whether knowing he had prostate cancer, or having cancer treatment, would improve or worsen his quality of life.
Having a digital rectal examination at the same time as a PSA test does not greatly increase the chance of finding a cancer, but can result in more men having unnecessary prostate biopsies. Digital rectal examination by primary care doctors (e.g. GPs) is not recommended as a standard test for men who do not have symptoms of prostate cancer.
What happens after a PSA test?
As a general guide, men should be offered more tests if the PSA result is higher than 3.0 nanograms per millilitre (3.0 ng/mL). Usually, the test should be repeated 1–3 months later.
Different types of PSA in a man’s blood (‘free’ PSA and ‘bound’ PSA) can be measured to provide more information. In some circumstances, a man’s doctor should ask the pathology laboratory to measure the free-to-total PSA percentage. This includes when men have a PSA test result that remains a little above 3.0 ng/mL on repeat testing, and when men have a PSA test result that is just below 3.0 ng/mL but have a high risk of prostate cancer.
If the results of blood tests show that a man could have prostate cancer, he should be offered a core biopsy of the prostate, which involves taking samples of prostate tissue using a special needle. A total of 21–24 cores should be taken from different areas within the prostate gland.
If a man’s first core biopsy does not find any prostate cancer, there is still a chance he could have prostate cancer or could develop prostate cancer. He should be offered check-ups, which usually involve regular PSA testing, and, increasingly, multiparametric magnetic resonance imaging (a type of MRI scanning that is available in some specialist centres). If these are abnormal, more biopsies may be needed.
Treatment options for prostate cancers found by PSA testing*
If prostate cancer is found on a core biopsy, a man can choose whether or not to have the cancer treated straight away. When prostate cancer grows slowly, as it quite commonly does, men may die of other causes before the prostate cancer becomes a problem. For an apparently slow growing cancer, the doctors may recommend that the man consider active surveillance instead of immediate active treatment. Choosing active surveillance could allow a man to avoid the problems that surgery or radiotherapy bring.
Active surveillance involves PSA tests every 3 months, rectal examination every 6 months, biopsies from time to time, and (in specialised centres) multiparametric MRI. If the cancer shows signs of growing, the man can have surgery or radiotherapy. In general, men with low-risk prostate cancer who choose this option instead of immediate prostate cancer treatment do not have a higher risk of dying from prostate cancer within the next 10 years. For men younger than 60 years, choosing active surveillance might just delay surgery or radiotherapy rather than avoid it.
Watchful waiting is another approach to monitoring a prostate cancer that was found as a result of PSA testing. It is mostly chosen when the cancer is already at an incurable stage, the man is unlikely to live for another seven years regardless of the prostate cancer or the man has decided not to have surgery or radiotherapy under any circumstances. Unlike active surveillance, a man on watchful waiting will generally not be offered potentially curative therapy if the cancer begins to grow. Treatment may be offered, however, to slow the growth of the cancer or to relieve symptoms. Watchful waiting involves regular PSA tests and clinic check-ups. Men with early prostate cancer who choose watchful waiting are more likely to have the cancer spread and are more likely to die of prostate cancer than if they had chosen immediate cancer treatment (e.g. radical prostatectomy or radiotherapy). On the other hand, men who choose immediate treatment are more likely to experience bladder, bowel or sexual problems than those who choose watchful waiting.
* This guideline makes recommendations about managing prostate cancers that are discovered as a result of PSA testing and follow-up. General information about prostate cancer treatments is available from Prostate Cancer Foundation of Australia.
Updating these recommendations
Medical research is constantly providing new evidence for the best ways to find and manage prostate cancer. Newly published literature relevant to each systematic review question will be monitored. If strong evidence supporting a change in the guideline accumulates, the Expert Advisory Panel will reconvene to assess if a guideline update is warranted. The guideline as a whole will be reviewed every 3 years and a decision made as to whether partial or full updating is required.