Sociocultural apects of PSA testing in Australia

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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:, cited 2023 Dec 10]. Available from:

This resource has been developed, reviewed or revised more than five years ago. It may no longer reflect current evidence or best practice.

Published: 2015

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These guidelines (recommendations) in the web-version of this guideline were approved by the Chief Executive Officer of the National Health and Medical Research Council (NHMRC) on 2 November 2015 under section 14A of the National Health and Medical Research Council Act 1992 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.

This chapter provides general information on sociocultural factors relevant to prostate-specific antigen (PSA) testing and the management of early prostate cancer. These include socioeconomic status, geographical factors, and ethnocultural factors including those relevant to Aboriginal and Torres Strait Islander men.

Search terms to identify evidence relevant to Aboriginal and Torres Strait Islander peoples were included in the systematic reviews for each clinical question, but no relevant evidence was identified for any question (see Technical report). Hence, there was insufficient evidence to make separate recommendations for Aboriginal and Torres Strait Islander peoples.


Socioeconomic characteristics are well-established health determinants, affecting one’s opportunities for, and access to, quality health care. Communities characterised as more socioeconomically disadvantaged, or in which health care is less accessible, tend to have shorter life expectancy and suffer from higher rates of illness, disability and death.[1]

Differences in prostate cancer diagnosis rates and outcomes have been observed for specific population groups, such as culturally and linguistically diverse communities, those from regional or rural areas, and groups with low socioeconomic status, when compared with the wider Australian population.[2] In order to reduce existing disparities, it is important to identify their needs and increase access to appropriate diagnostic and treatment programs and services.

Socioeconomic status

Several studies have demonstrated variations in prostate cancer incidence and mortality rates between men of different socioeconomic status. Between 2001 and 2005, the age-standardised incidence of prostate cancer in New South Wales was highest among men in the least disadvantaged quintile (171 per 100,000) and lowest in the most disadvantaged quintile (126 per 100,000).[3] However, prostate cancer incidence rates in the second, third and fourth quintiles were not significantly different from the New South Wales average. While differences were observed in prostate cancer incidence, age-standardised mortality rates showed no significant variations across quintiles.[3]

National cancer data obtained between 2006 and 2010 have shown that men in the least disadvantaged quintile had a higher 5-year survival rate than men in any of the other quintiles.[4] A study that used record linkage demonstrated significant differences in patterns of surgical care and all-cause mortality across the gradient of socioeconomic status in Western Australia, using the Index of Relative Socioeconomic Disadvantage (IRSD).[5] Compared with men in the least disadvantaged category, men in the most disadvantaged category were less likely to undergo radical prostatectomy (relative risk [RR] 0.63; 95% confidence interval [CI] 0.47–0.83) and had a higher all-cause mortality in the 3 years after a prostate cancer diagnosis (RR 1.34; 95% CI 1.10–1.64).5 The risk of dying within 3 years of diagnosis was also lower for men with private health insurance than for men without private health insurance (RR 0.82; 95% CI 0.76–0.89), and for men admitted to a private hospital than for those admitted to a public hospital (RR 0.77, 95% CI 0.71–0.84).[5]

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Geographical factors

The Australian Bureau of Statistics Australian Standard Geographic Classification (ASGC) Remoteness Areas is one of the geographical classifications that is currently used in Australia. It allocates areas to one of five categories: major cities, inner regional, outer regional, remote and very remote.[6] More than half of Australia’s outer regional, remote and very remote population reside in areas of socioeconomic disadvantage.[7] The highest age-standardised incidence rate for prostate cancer was observed in inner regional areas (186 per 100,000) compared with all other regions of Australia.[2]

From 1993 to 2007, prostate cancer mortality rates fell for men in both urban and rural areas. However, studies have continued to show a significant difference between the two.[8] [9] An Australian population-based study assessing urban-rural differences in prostate cancer testing and outcomes between 2000 and 2002 found a 21% (95% CI 14%–29%) higher age-standardised prostate cancer mortality among men living in rural areas compared with those living in capital cities. The authors hypothesised that such an excess could be related to the lower uptake of PSA testing and radical prostatectomy in rural areas.[8] Population-based data from 2001 to 2010 were analysed and showed no improvement in age-standardised prostate cancer mortality ratios for men in rural areas compared with those in metropolitan areas, from 1.17 (95% CI 1.13–1.21) in 1997–2000 to 1.18 (95% CI 1.15–1.21) in 2006–2010.[10]

Cancer registry data and hospital admission records between 1993 and 2002 were linked to determine the differences in surgical care for prostate cancer between men in urban and rural areas of New South Wales. Men from less accessible areas were more likely to undergo bilateral orchidectomy (RR 1.36; 95% CI 1.26–1.47) and less likely to have radical prostatectomy (RR 0.69; 95% CI 0.65–0.73).[11] An analysis of five-year relative survival by geographic remoteness of New South Wales found a three-fold higher relative excess risk (RER) of death from prostate cancer (RER 3.38; 95% CI 2.21–5.16) among rural residents than those in highly accessible areas.[12]

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Aboriginal and Torres Strait Islander men

Aboriginal and Torres Strait Islander men in Australia are less likely to be diagnosed with prostate cancer, compared with non-Aboriginal Australian men.[13][14] Data collected from the Northern Territory Cancer Registry between 1991 and 2001 showed an incidence rate ratio of 0.2 (95% CI 0.1–0.3) for Aboriginal men compared with the whole Australian population.[15] Aboriginal men from the Northern Territory were also less likely to die from prostate cancer, indicated by a mortality rate ratio of 0.4 (95% CI 0.2–0.8).[16]

While Aboriginal men were less likely to be diagnosed with or die from prostate cancer, they have been shown to have a lower 5-year survival rate after the diagnosis of prostate cancer.[13] By linking data from the New South Wales Cancer Registry with New South Wales hospital inpatient records, Aboriginal men were found to have a 53% higher risk of death from prostate cancer in the 5 years following a diagnosis.[17]

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Ethnicity and race

Analyses have shown that men born overseas have a lower age-standardised prostate cancer incidence rate, indicating a lower risk of diagnosis when compared to Australian-born men.[2] Age-standardised prostate cancer incidence was highest in Australian-born New South Wales residents (136.5 per 100,000), followed by those born in English-speaking countries (116.7 per 100,000) and in non-English speaking countries (89.0 per 100,000).[3]

Similar to age-standardised prostate cancer incidence, the age-standardised prostate cancer mortality rate was higher in Australian-born men.[2] In New South Wales, analysis of routinely collected data showed a significantly lower risk (age-adjusted) of prostate cancer deaths among East Asian and Southeast Asian migrants in their first 9 years of residence in Australia (RR 0.39; 95% CI 0.25–0.61) compared with Australian-born men. This initial lower risk of death, however, increased over time and reached that of Australian-born men by the third decade of residence in Australia.[18]

Variations in PSA testing by country of birth were reported in a cross-sectional analysis. Only men from East Asia had a significantly lower use of PSA tests than Australian-born men, while uptake of tests increased with increasing time of residence in Australia.[19]

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  1. Australian Institute of Health and Welfare. Australia's Health 2012. Canberra; 2012. Report No.: Cat No AUS156.
  2. 2.0 2.1 2.2 2.3 Australian Institute of Health and Welfare. Prostate cancer in Australia. Canberra: AIHW; 2013. Report No.: no. 79. Cat. no. CAN 76. Available from:
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  13. 13.0 13.1 Australian Institute of Health and Welfare. Cancer in Aboriginal and Torres Strait Islander peoples of Australia: an overview. Canberra: AIHW; 2013. Report No.: Cat No CAN75.
  14. Condon JR, Armstrong BK, Barnes A, Cunningham J. Cancer in Indigenous Australians: a review. Cancer Causes Control 2003 Mar;14(2):109-21 Available from:
  15. Condon JR, Armstrong BK, Barnes T, Zhao Y. Cancer incidence and survival for indigenous Australians in the Northern Territory. Aust N Z J Public Health 2005;29, (2) 123-128.
  16. Condon JR, Barnes T, Cunningham J, Armstrong BK. Long-term trends in cancer mortality for Indigenous Australians in the Northern Territory. Med J Aust 2004 May 17;180(10):504-7 Available from:
  17. Treatment and survival outcomes for prostate cancer for Aboriginal men in New South Wales (NSW) Australia. Smith D, Rodger J, Supramaniam R, Gibberd A, Saunders V, O'Connell D In: Smith D, Rodger J, Supramaniam R, Gibberd A, Saunders V, O'Connell D. Prostate Cancer World Congress & 14th Australasian Prostate Cancer Conference Melbourne. BJU Int; 2013. p. 10.
  18. McCredie M, Williams S, Coates M. Cancer mortality in East and Southeast Asian migrants to New South Wales, Australia, 1975-1995. Br J Cancer 1999 Mar;79(7-8):1277-82 Available from:
  19. Weber MF, Banks E, Smith DP, O'Connell D, Sitas F. Cancer screening among migrants in an Australian cohort; cross-sectional analyses from the 45 and Up Study. BMC Public Health 2009 May 15;9:144 Available from: