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PROSTATE cancer screening guidelines need an urgent update to account for new technology that tips the balance of potential benefits and harms “very heavily” in favour of prostate-specific antigen (PSA) testing, an expert says.
Professor Mark Frydenberg, a former president of the Urological Society of Australia and New Zealand, was on the committee that produced the current clinical practice guidelines on PSA testing in 2016.
The guidelines recommend that men aged 50–69 years be offered biennial PSA testing if they make an informed decision to be screened. Men aged 70 years and older, the guidelines recommend, should be advised that the harms of PSA testing may be greater than the benefits in their age group.
However, just 5 years after their release, Professor Frydenberg told InSight+ the guidelines were “outdated and in urgent need of review”.
“The guidelines need to move away from a formal age cut-off, toward estimations of life expectancy in the person over 70 years,” he said.
“For a 70–75-year-old who is in very good health and doesn’t have a lot of comorbidities – who has a greater than 10-year life expectancy – it’s not unreasonable to consider PSA testing.”
Professor Frydenberg said the change in thinking was partly due to men living healthier and longer lives since the foundational 1990s study on which the guidelines were largely based.
However, the biggest change since 2016 has been the uptake of new diagnostic technology, which reduced the harms associated with screening, Professor Frydenberg said.
First, the follow-up test for an elevated PSA is no longer a biopsy, but a Medicare-funded multiparametric magnetic resonance imaging (MRI) scan after a repeat PSA with free/total PSA.
“This stratifies the 50% of patients with high PSA levels who actually need a biopsy, and reduces false positive PSA results that previously led to unnecessary biopsies in men without cancer,” Professor Frydenberg said.
Second, biopsies are now done transperineally, rather than transrectally, reducing the chances of infection.
“We used to see a lot of readmissions after biopsies due to infection, but that risk has dropped to basically zero,” Professor Frydenberg said.
Furthermore, the management of patients with prostate cancer has changed.
“Prior to 2016, virtually everyone diagnosed with prostate cancer ended up having radiotherapy or surgery, with all the potential quality-of-life side effects,” Professor Frydenberg said.
“Now a large number of men are deemed to have low-risk prostate cancer and don’t need surgery or treatment at all and are managed closely with surveillance.
“There’s been a whole paradigm shift since 2016, which heavily tips the balance of potential benefits and harms in favour of PSA testing,” he said.
Overall, Professor Frydenberg said the value of early detection and treatment was a 25–40% reduced mortality rate over 10–15 years, with greater benefits if higher grade cancers were diagnosed in younger age groups.
However, Professor Paul Glasziou, director of the Institute for Evidence-Based Healthcare at Bond University, said the problem of prostate cancer overdiagnosis persisted despite new technology.
“I agree that the Medicare-funded MRI scan is helpful, especially in reducing unnecessary biopsies and their complications,” Professor Glasziou told InSight+.
“However, it is unclear whether MRI reduces overdiagnosis, and if so by how much – we don’t have enough information yet.
“We’ve estimated that 43% of current prostate cancer is overdiagnosed in Australia,” he said.
“Since the potential for overdiagnosis increases with age, that is a concern for older men; about 50% over 70 years will have latent prostate cancer, most of which would never present clinically.”
Professors Frydenberg and Glasziou were commenting following the publication of a research letter in the MJA which suggests patterns of PSA testing in general practice fall wide of the guidelines’ recommendations for older men.
Among men aged 70–74 years, 46% received at least two PSA tests within 2 years, according to the study of electronic data from 180 Victorian general practices between 2016 and 2018. A total of 78 818 tests were recorded from a sample of 142 016 men aged 40 years and older – 29% from men aged 70 years and older.
One of the letter’s co-authors, Associate Professor Christopher Pearce, research director at Outcome Health, said the findings were likely to reflect a “complex mix of often social things”.
“In that older age group, there is an increase in symptoms, plus they are more likely to know someone who has had it, plus the guidelines are just guidelines, and there is still a lot of media stuff about screening,” he said.
“Also, this group is more likely to have a result, the recommendation of which is to repeat [the test].”
Professor Jon Emery, Herman Professor of Primary Care Cancer Research at the University of Melbourne, commented:
“What the electronic medical record data can’t tell us is how much shared decision making is occurring in relation to the PSA tests being ordered.
“The bottom line has to remain that GPs need to have a discussion about potential benefits and harms of a PSA test whatever the age of the patient.”
Professor Frydenberg agreed.
“PSA testing is not something GPs should be routinely ordering together with cholesterol and a full blood count. There needs to be a conversation based on the data.
“For the patient who is unlikely to survive 7–10 years, I use the often-stated adage that in their particular situation ‘you’re more likely to die with it rather than of it’ given the slow growth rate of many prostate cancers.”
Good communication could also reduce the psychological harms associated with a potential cancer diagnosis, he said.
“If things are clearly explained before a biopsy, a patient can experience relief if they are found to have low-risk prostate cancer.”
Online tools might also assist, he added, citing the NAVIGATE trial which is giving prostate cancer patients access to resources to ensure they are comfortable having a low-risk cancer monitored instead of treated.
The authors of the MJA research letter noted PSA levels in their data matched current age-specific 95th percentile reference ranges.
The 2016 guidelines countenanced the future use of > 95th percentile for age as the criterion for further investigation. However, all of the clinicians who spoke with InSight+ favoured the continued use of > 3.0 ng/mL and free/total PSA.
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It is hard to trust the opinions of people who use the term ‘overdiagnosis’ to mean ‘over-treatment’.
With every diagnosis, from an ingrown toenail to COVID to cancer, there are various therapeutic options. In this country the law is that the patient must be allowed to make his decision based on the receipt of information adequate to his desires. It is not ethical to withhold information from a competent adult.
That may mean telling someone that he has cancer but you advise not to treat it, but that is a very different situation from implying that ‘overdiagnosis’ is erroneous diagnosis.
Prostate cancer, like ovarian cancer, has vague symptoms which are easily confused with benign processes. As a resident/registrar I saw many men with a fractured femoral shaft, or spinal cord compression, as their initial presentation of prostate cancer. Now the blood test is readily available, my GP recommends it and I have no qualms having it. Becoming paraplegic when you cough is an unpleasant event, whatever your age/life expectancy.
And again, in todays papers…
“Too many men over 70 who have no symptoms are being tested according to new research.”
It then goes on to detail the so-called negative effects of over-treatment..!
What new research..? It’s out of date already, but more likely now being promoted as a purely cost saving measure. For heavens sake, the PSA is not an expensive test..!
The most relevant point, apparently overlooked by the authors of this missive, and by so many others, is…OFTEN, THERE ARE NO SYMPTOMS..! Something I can personally vouch for..!
The problem is, we still have this kind of article appearing in our medical press. Just today, appearing in a popular medical newsletter under the heading…”Older Aussies at risk over high PSA uptake”.
https://medicalrepublic.com.au/older-aussies-risk-overtreatment-with-high-psa-uptake/48740?utm_source=TMR%20List&utm_campaign=8abe9aea62-Newsletter_July_13_07_21&utm_medium=email&mc_cid=8abe9aea62&mc_eid=8a16f47967
The sexist and agist rubbish that has been disseminated about prostate cancer and men’s health in general is shameful and ignores so many facts about the disease and PSA testing that it has to change. The advice to avoid screening and diagnosing a potentially lethal cancer has never been applied to breast cancer despite mammography being both less cost effective and less safe for finding localised disease.
PSA levels do vary over time, but not more so in older men. To the contrary, they vary more in young men and the answer is case appropriate counselling and serial testing. This disease kills untreated men horribly. Brain and bone mets are not a reasonable alternative to early (or should I say unnecessary) diagnosis. The diagnostic options and the advantage of fractionated modern EBR, plus the declassification of Gleeson 6 as cancer have changed the playing fields for invasive biopsy and surgical treatment.
While there are still concerns about missing high grade, lethal cancers, clearly limiting screening to biannually in younger men increases that risk. Why biannual PSA? Answer, because GPs can’t be trusted and the MBS values the $ more than mens health. Annual PSA testing offers advantages that ignoring men or sticking your finger up bums and missing small, anterior and proximal lesions never has.
I have diagnosed and given so many men the options they deserve for the management of their cancer using this simple test and when appropriate serial PSA testing and medical imaging. It’s a no brainer the guidelines have to change. They should never have been developed in the first place.
Don’t even start me on hormonal health and gender inequality. Men deserve better from the medical profession.
In 1992 age 60, my PSA started rising . No MRIs then, so had biopsy, which showed ow grade carcinoma. On hearing this 3 friends had PSA and +ve biopsies
Over the years in GP I have seen quite a few patients dying with their painful metastases
2 of us decided to have surgery and 2 decided to watch and wait
the 2 who had surgery are alive and well aged 88 and 90. The other 2 died a long time ago
I must confess missing sex from aged 60, but you only live once and there is more to life than intercourse
Maybe to underpin the validity of the recommended upscaling of the whole screening approach discussed in the article, and aside from the comments some of us with personal experience have made, just think of how many public figures or identities – some might even call them celebrities – who have been featured in the news lately as “sadly, succumbing after a long battle with prostate cancer…” And, as we all know, it is not a nice way to die..!
Well, the reason most of them ‘succumbed’ was because they were diagnosed too late for curative measures in the main. Most ca prostates now should, and could, be successfully treated – the rider being – as long as detected early enough. The only way to do that is a sensible screening process, for now the PSA being the only test readily and quite cheaply available, but better ones will emerge. While at the same time ensuring the first move, once suspected, is NOT biopsy..! There are now better ways of following these cases up, with several different imaging modalities, and if biopsy is indicated, best done by trans-perineal approach to lessen the risk of septicaemia.
Then, if diagnosis is confirmed, the best treatment should be considered and discussed, with all options on the table for truly informed consent. Not just the near automatic recommendation for surgery which sadly still tends to be the case.
What about the men with Gleeson score 9 or 10 and other aggressive features? There is so much emphasis on avoiding harm to low risk cancers, that really aggressive prostate cancers are called “High Risk” rather than the aggressive , deadly cancers that they are. It seems to change the mindset of the treating doctors – aggressive breast cancers are treated much more actively and with curative intent. It seems that if you are unfortuante enough to be male with an aggressive prostate cancer, curative intent is disregarded.
A few extra MRIs seems to be a low price to pay to find the “High Risk” cancers which are going to kill aggressively.
The essential difficulty with PSA screening is that many have had what eventually proved to be unnecessary interventions; Thankfully MRI has come along and has allowed many biopsies to be avoided – including on me, now in my 70s with a slowly rising PSA over the past five years. Under the care of a urologist, I have a yearly PSA including free/bound ratio, and MRI if any concern. The current approach of screening for prostate cancer if projected life expectancy is 10 years or more seems more sensible than an arbitrary age cutoff.
Ya think?
Over past ten years I have had two truss biopsies three prostate mris one biopsy under mri found to be scar tissue from prior biopsy.
It is difficult for the urologist not to investigate when patient presents with elevated PSA
especially another doctor
Couldn’t agree more. In my own case, which is a good example of how the suggested management in the article should go. I had PSAs done when I had my biannual bloods done, as I did for all my men over 45. When my PSA started climbing I did it 6 monthly, and when it reached 20 quite quickly I paid for my own mpMRI. (Not on Medicare back then late 2016)
That did confirm a couple of foci of ca. Trans-perineal biopsies, which were then able to target both spots, confirmed Gleason 3 + 4. I chose stereotactic EBR, enhanced by trans-perineal markers and space-oar (=spacer for organs at risk), in collaboration with my urologist and the public radiation oncology dept, (2017) and subsequent near zero PSAs are consistent at 5 yrs with complete cure.
I declined androgen suppression therapy knowingly, having keenly studied anti-aging tactics, and what near zero testosterone levels do to one’s physiology, and having seen the effects in other patients. I am glad I did. I had minimal side effects, no loss of function compared to before the treatment, and never missed a day’s surgery throughout the treatment.
At the time I was a fit 70 yr old, and was not impressed when told if I did nothing, it would probably only kill me by 80. Bugger that..! I had things to do – places to visit..!
I agree.
A urologist told him he had cancer.
Second opinion sought.
He had a biopsy.
No cancer.