Guidelines developed in partnership with
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
National Health and Medical Research Council
The guidelines have been produced by a process of systematic literature review; critical appraisal and consultation encompassing all interested parties in Australia (see Appendix 1).
This guideline includes evidence-based recommendations (EBR), consensus-based recommendations (CBR) and practice points (PP) as defined in Table 4. Recommendations and practice points were developed by working party members and sub-committee members.
Each EBR was assigned a grade by the expert working group, taking into account the volume, consistency, generalisability, applicability and clinical impact of the body of evidence supporting each recommendation – see Table 2.
Information about levels of evidence can be found in the Evidence Summaries for each recommendation in each chapter.
Recommendations
Risk
The question does not lead to a recommendation.
Testing
PSA Testing strategies
Recommendation | Grade |
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C |
Consensus-based recommendation(s) |
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![]() If initial PSA is at or below the 75th percentile for age, advise no further testing until age 50. If initial PSA is above the 75th percentile for age, but at or below the 95th percentile for age, reconfirm the offer of testing every 2 years. If a PSA test result before age 50 years is greater than the 95th percentile for age, offer further investigation. Offer testing from age 50 years according to the protocol for all other men who are at average risk of prostate cancer. |
![]() iii This Consensus-based recommendation assumes testing with the criterion for further investigation a PSA of ≥ 3 ng/mL. This recommendation will be a high priority for reconsideration when the Australian model of PSA testing has been completed. For example, use of the 95th percentile for age in place of ≥ 3 ng/mL might improve appreciably the balance of harms to benefits of testing in men 70–74 years of age. |
![]() For men whose risk of prostate cancer is estimated to be at least 9–10 times higher than average due to the presence of risk factors (e.g. father and two brothers diagnosed with prostate cancer), and who decide to undergo testing after being informed of the benefits and harms, offer testing every 2 years from age 40–69 years. If initial PSA is at or below the 75th percentile for age, advise no further testing until age 50. If initial PSA is above the 75th percentile for age, but at or below the 95th percentile for age, reconfirm the offer of testing every 2 years. If a PSA test result before age 50 years is greater than 95th percentile for age, offer further investigation. Offer testing from age 50 years according to the protocol for men who are at average risk of prostate cancer. |
Role of digital rectal examination
Recommendation | Grade |
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C |
Practice point(s) |
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PSA testing and life expectancy
Recommendation | Grade |
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C |
Practice point(s) |
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(The table is provided at the bottom of this page)
Testing with variants of PSA to improve sensitivity after an initial total PSA ≤ 3.0 ng/mL
Recommendation | Grade |
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D |
Consensus-based recommendation(s) |
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Testing with variants of PSA or repeat PSA testing to improve specificity after an initial total PSA > 3.0 ng/mL
Recommendation | Grade |
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![]() For those with initial total PSA greater than 3.0 ng/mL and up to 5.5 ng/mL, measure free-to-total PSA percentage at the same time as repeating the total PSA. |
D |
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D |
Consensus-based recommendation(s) |
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Decision support for men considering PSA testing
Recommendation | Grade |
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C |
Practice point(s) |
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Prostate biopsy and multiparametric MRI
Biopsy quality criteria
Recommendation | Grade |
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B |
Practice point(s) |
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Follow-up to a negative prostate biopsy
Recommendation | Grade |
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![]() Monitor more closely men with abnormal findings on pre-biopsy digital rectal examination, and those whose biopsy findings included either atypical small acinar proliferation or high-grade prostatic intra-epithelial neoplasia. In addition to further PSA testing and digital rectal examination, consider prostate imaging with investigations that can help to localise the site of cancer within the prostate, and repeat biopsy using a targeted approach. |
D |
![]() Do not offer another biopsy if the multiparametric MRI (using T2- and diffusion-weighted imaging) is negative, unless any of the following risk factors are present:
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D |
Practice point(s) |
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![]() iv Refer to Urological Society of Australasia position statement: Status of mp-MRI prostate 2012: report from the MRI Prostate Working Party (available at www.usanz.org.au). |
![]() v See Moore CM, Kasivisvanathan V, Eggener S, et al. Standards of reporting for MRI-targeted biopsy studies (START) of the prostate: recommendations from an International Working Group. European urology 2013; 64: 544-552. |
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Active surveillance and watchful waiting
Active surveillance
Recommendation | Grade |
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C |
Practice point(s) |
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Consensus-based recommendation(s) |
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For men aged less than 60 years, consider offering active surveillance based on the above criteria, provided that the man understands that treatment in these circumstances may be delayed rather than avoided. |
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If the man strongly prefers active surveillance, offer repeat biopsy to ensure that disease classification is accurate. |
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If the man strongly prefers active surveillance, offer repeat biopsy. |
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![]() Offer repeat biopsies every 2–3 years, or earlier as needed to investigate suspected disease progression: offer repeat biopsy and/or multiparametric MRI (in specialised centres) if PSA doubling time is less than 2–3 years or clinical progression is detected on digital rectal examination. |
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Watchful waiting
Recommendation | Grade |
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C |
Practice point(s) |
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Consensus-based recommendation(s) |
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![]() Source: adapted from [UK] National Collaborating Centre for Cancer. Prostate cancer: diagnosis and treatment. National Collaborating Centre for Cancer; 2014. |
![]() If there is no evidence of significant disease progression (as indicated by 3–4 monthly PSA levels over 1 year and absence of relevant symptoms), continue monitoring by 6-monthly PSA levels. If there is evidence of significant disease progression (that is, relevant symptoms and/or rapidly-rising PSA level), refer to a member of the treating team (urologist, medical oncologist or radiation oncologist) for review. |
PSA testing and life expectancy
Age | Percentage of men remaining alive after 7 years |
50 | 97% |
55 | 96% |
60 | 94% |
65 | 91% |
70 | 85% |
75 | 74% |
80 | 57% |
85 | 37% |
90 | 19% |
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