Prostate cancer remains a significant health concern in Australia, with approximately 26,000 men diagnosed each year. The disease is particularly prevalent among older men, with over 85% of cases occurring in those over the age of 60. Despite its high incidence, many prostate cancers progress slowly, leading to a situation where men often die “with” rather than “from” the disease.
Currently, prostate cancer is detected using a blood test that measures the levels of prostate-specific antigen (PSA), a protein produced by the prostate gland. While elevated PSA levels can indicate prostate cancer, they may also arise from non-cancerous conditions such as prostate enlargement or inflammation. To address these concerns, new draft guidelines from the Prostate Cancer Foundation of Australia are proposing revised recommendations for PSA testing.
Balancing Early Detection and Over-Diagnosis
Early detection of prostate cancer is crucial as it allows for timely interventions, including prostate removal surgery, radiation, or hormonal therapy. Nevertheless, these treatments can lead to side effects such as erectile dysfunction and urinary incontinence, affecting up to 14% of patients. For men with low-risk prostate cancer that has not spread, clinicians may recommend “active surveillance” to monitor the condition instead of immediate treatment. This approach can help avoid unnecessary side effects and preserve quality of life.
The controversy surrounding PSA testing lies in its potential for over-diagnosis. While a decades-long clinical study of 182,000 men indicated that PSA testing reduced prostate cancer deaths by 20%, it also revealed that approximately 48 men must be over-treated to prevent one death. Striking a balance between facilitating early detection and preventing harmful over-treatment remains a critical challenge.
Key Recommendations from the Draft Guidelines
The new draft guidelines propose several changes aimed at reducing over-treatment and minimizing harm to patients:
1. **Baseline PSA Test at Age 40**: The guidelines recommend that all men receive an initial PSA test at 40 years old. This baseline measurement can help track PSA levels over time, allowing for better identification of aggressive tumors that require prompt treatment.
2. **Regular Testing for Men Aged 50-69**: General practitioners are encouraged to offer PSA tests every two years for men aged 50 to 69 years. For men over 70, testing would be determined based on clinical assessments. This approach considers individual health factors and life expectancy, aiming to reduce the incidence of over-diagnosis.
3. **Targeting High-Risk Populations**: The guidelines emphasize the importance of early and frequent PSA testing for men with a family history of prostate cancer and for Aboriginal and Torres Strait Islander men, who have a higher risk of developing and dying from the disease.
Traditionally, men with elevated PSA levels underwent needle biopsies, a procedure that can be uncomfortable and carries risks of bleeding or infection. The new guidelines no longer recommend the use of digital rectal examinations—often referred to as the “finger up the bum”—as part of routine screening. Instead, they advocate for advanced imaging techniques, such as multiparametric MRI (mpMRI), to assist in determining whether a biopsy is necessary.
Since 2018, Medicare has provided rebates for MRI diagnostics, allowing medical specialists to use this technology to assess prostate conditions more accurately. The draft guidelines suggest that mpMRI can supplement PSA testing, thereby reducing the need for invasive procedures and minimizing the financial burden on the healthcare system.
The Prostate Cancer Foundation is currently seeking public feedback on these draft guidelines. Once finalized, the recommendations will be submitted to the National Health and Medical Research Council for approval before being implemented in clinical practice.
Kevin M. Koo, who receives funding from the Prostate Cancer Foundation of Australia, emphasizes the need for ongoing dialogue and research to refine prostate cancer detection strategies, ensuring that patient care remains at the forefront of medical advancements.
