Policy context

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Policy context

There is currently no formal, population-based screening program for prostate cancer in Australia. However, extensive individual screening does occur, as shown by increasing rates of prostate specific antigen (PSA) testing[1].

On a per capita basis, PSA tests for screening were provided to one in four Australian men aged 55-75 years in 2010-11[2][3]. This is not much lower than annual breast and cervical cancer screening rates among target populations, so it can be reasonably said that Australia has a de facto national, population-based screening program for prostate cancer.

The screening of asymptomatic men with the PSA test, with or without digital rectal examination (DRE), with the aim of detecting prostate cancer continues to be widely debated.

The joint position of Cancer Council Australia and the Australian Health Ministers’ Advisory Council is that the harm of screening asymptomatic men for prostate cancer on a population basis outweighs the benefit. It is therefore recommended that men considering being screened for prostate cancer make an individual decision after being fully informed about both the benefits and harms of testing and treatment. Men are advised to discuss with their GP; the Royal Australian College of General Practitioners, which also supports informed individual choice instead of population screening, provides decision-making aids to GPs advising men about whether or not to have a PSA test.

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Recommendations of other organisations

The Royal Australian College of General Practitioners does not recommend population or routine screening of asymptomatic men. It recommends that patients should make their own decision about being screened for prostate cancer after being fully informed of the associated risks, benefits and uncertainties[4].

Andrology Australia, the peak body for male reproductive health and associated chronic diseases, also supports informed individual choice instead of population-based screening[5].

The Urological Society of Australia and New Zealand recommends that men aged 55-69 years should be offered PSA and DRE testing after receiving information about the risks and benefits of screening. Men in younger age groups who are interested in their prostate health could have an initial PSA test and DRE performed at or beyond age 40, as an indicator of their future risk of developing prostate cancer. The intensity of subsequent monitoring would be adjusted in line with their assessed level of risk[6].

The Royal College of Pathologists of Australasia recommends that men seeking to assess their prostate cancer risk should be offered PSA/DRE from age 40 as a baseline measure of risk. Men with high PSA levels for their age should be screened annually, while those with low levels could be screened less frequently[7].

The Prostate Cancer Foundation of Australia recommends that men at age 50 with no family history of prostate cancer and men at age 40 with a family history should seek voluntary annual PSA/DRE testing[8].

In 2010, the American Cancer Society recommended

... that asymptomatic men who have at least a 10-year life expectancy have an opportunity to make an informed decision with their healthcare provider about screening for prostate cancer after they receive information about the uncertainties, risks, and potential benefits associated with prostate cancer screening. Prostate cancer screening should not occur without an informed decision-making process. Men at average risk should receive this information beginning at age 50 years. Men in higher risk groups should receive this information before age 50 years. Men should either receive this information directly from their health care providers or be referred to reliable and culturally appropriate sources. Patient decision aids are helpful in preparing men to make a decision whether to be tested[9].

In 2011, the US Preventative Services Taskforce reviewed the evidence relating to prostate cancer screening and concluded with 'moderate certainty' that the harms of PSA-based screening outweigh the benefits. In a draft recommendation based on this review, they recommend against PSA-based population screening for prostate cancer in all age groups[10].

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The role of general practice

Responsibility for advising men about PSA screening rests mostly with GPs, who face the difficulties of explaining the complex risks, benefits and uncertainties about the test while balancing conflicting viewpoints and unclear medico-legal risks[11].

GPs and other relevant health professionals should be educated and resourced to enable them to adequately inform men of the benefits and risks of testing for prostate cancer and to enable men to make an informed decision as to whether or not they should be screened.

Evaluations of GP education workshops have shown that as participants’ knowledge about PSA screening and level of understanding increased, they were more likely to initiate discussions with patients about the risks and benefits of the test, and they were more confident in doing so[11][12].

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Opportunities for improved guidance

As this chapter indicates, the relative inaccuracy of the PSA test has given rise to varied recommendations and practices in relation to prostate cancer screening and follow-up – not just on the use of the PSA test itself, but also on when to biopsy the prostate and other decisions about patient care. One fact is undisputed: the use of PSA screening in asymptomatic Australian men is highly prevalent. The widespread use of PSA screening, in the absence of clearer guidance, has led to calls for the development of national, consensus guidelines and follow-up based on the limited evidence available.

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References

  1. Australian Institute of Health and Welfare, Australasian Association of Cancer Registries. Cancer in Australia: an overview, 2006. Canberra: AIHW; 2007. Report No.: Cancer series no. 37. Cat. no. CAN 32. Available from: http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=6442454559.
  2. Australian Bureau of Statistics. Population by age and sex, Australian states and territories. Canberra: ABS; 2010 Jun. Report No.: Cat no 3201.0. Available from: http://www.abs.gov.au/Ausstats/abs@.nsf/mf/3201.0.
  3. Medicare Australia Statistics. Requested Medicare items processed from July 2010 to June 2011. [homepage on the internet] Canberra: Australian Government Department of Human Services; 2013 Apr 24 [cited 2011 Oct 18; updated 2011 Oct 18]. Available from: https://www.medicareaustralia.gov.au/cgi-bin/broker.exe?_PROGRAM=sas.mbs_item_standard_report.sas&_SERVICE=default&DRILL=ag&_DEBUG=0&group=66655&VAR=services&STAT=count&RPT_FMT=by+state&PTYPE=finyear&START_DT=201007&END_DT=201106.
  4. RACGP National Standing Committee. Quality care 2009: prostate screening. Policy endorsed by the 51st RACGP Council. Melbourne: RACGP; 2009 May 6.
  5. Andrology Australia. Andrology Australia statement on PSA testing for prostate cancer. Melbourne: Andrology Australia; 2015 Jul Available from: https://www.andrologyaustralia.org/wp-content/uploads/review-early-detection-of-prostate-cancer.pdf.
  6. Urological Society of Australia and New Zealand. Urological Society of Australia and New Zealand PSA testing policy. Edgecliff, NSW: USANZ; 2009 Available from: http://www.usanz.org.au/uploads/29168/ufiles/USANZ_2009_PSA_Testing_Policy_Final1.pdf.
  7. McKenzie PR, Delahunt B, Kench JG, Ross B, Lam Q, Devoss K, et al. Prostate specific antigen testing: age-related interpretation in early prostate cancer detection. Pathology 2013 Apr 24 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23619589.
  8. Prostate Cancer Foundation of Australia. PCFA policy statement: PSA/DRE testing for early detection of prostate cancer. Sydney: PCFA; 2006 Available from: http://www.prostate.org.au/articleLive/attachments/1/PCFA%20PSA%20%20DRE%20Policy%20Statement%20270706.pdf.
  9. American Cancer Society Prostate Cancer Advisory Committee, Wolf AM, Wender RC, Etzioni RB, Thompson IM, D'Amico AV, et al. American Cancer Society guideline for the early detection of prostate cancer: update 2010. CA Cancer J Clin 2010 Mar;60(2):70-98 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20200110.
  10. U.S. Preventive Services Task Force. Screening for prostate cancer: draft recommendation statement. Rockville, MD: USPSTF; 2011 Available from: http://www.uspreventiveservicestaskforce.org/uspstf12/prostate/draftrecprostate.htm.
  11. 11.0 11.1 Steginga SK, Pinnock C, Baade PD, Jackson C, Green A, Preston J, et al. An educational workshop on the early detection of prostate cancer--a before-after evaluation. Aust Fam Physician 2005 Oct;34(10):889-91 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16217583.
  12. Metcalfe R, Russell R, McAvoy B, Tse J, Sutherland G, Hoey L. Promoting shared decision making and informed choice for the early detection of prostate cancer: development and evaluation of a GP education program. Cancer Forum 2006 Mar;30(1):38-42 Abstract available at http://www.cancerforum.org.au/File/2006/March/CF06Mar_38-42.pdf.

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