Should you routinely test your patients for prostate cancer?
Published in Health News and Evidence
Date published: About this date
Current evidence is insufficient to determine whether early detection and treatment of prostate cancer can improve disease outcomes or cancer mortality. The latest evidence suggests any potential benefit from early detection is likely to be small.
Most guidelines in Australia recommend against routine testing for prostate cancer, as it may cause more harm than good. However, if a man asks about a test for prostate cancer he needs to be fully informed of the benefits and risks to make an informed decision.
Complex factors are associated with prostate cancer testing. It may be difficult to fully explain the issues to your patient during a consultation, but having an understanding of the latest evidence will help.
It is not surprising that prostate cancer is a growing concern for Australian men. It is the most commonly diagnosed cancer and the second leading cause of cancer-related deaths. In Australia in 2012 alone, 18,560 new cases were diagnosed and 3235 men died of the disease.1
What is perhaps surprising is the increase in routine testing for prostate cancer being performed (Figure 1). Since its introduction to Australia in 1988 there has been a substantial increase in prostate specific antigen testing. The age-standardised rate of PSA testing in NSW increased from 1284 per 100,000 men in 1989 to a rate of 12,119 per 100,000 in 2006.2
This increase in PSA testing may have contributed to a significant increase in the number of prostate cancers diagnosed and a halving of the number of cases of advanced prostate cancer at diagnosis. But what effect is the increase in testing having on your patients?
The advice is that men who are considering prostate cancer testing should be informed about the potential benefits, risks and uncertainties of the test and assisted to make an informed decision.3,4
However, consumers and health professionals receive conflicting messages about testing. For example, some consumer advocacy groups encourage men to have a PSA test as part of their regular health check.5
To help resolve the confusion, the NHMRC has established a PSA Testing Expert Advisory Group. They will review the evidence on whether PSA testing of asymptomatic men, with or without DRE, reduces mortality and morbidity, and the harms and other benefits of PSA testing and of subsequent follow-up investigations and treatment.6
However, until this information is available, should you offer your patients a test for prostate cancer?
Table 1. Australian guidance about prostate cancer testing
Population screening for prostate cancer with DRE, PSA test or transabdominal ultrasound is not recommended. If a man specifically asks for it and is fully counselled on the pros and cons he should be tested using both PSA and DRE
PSA testing is not suitable for population screening, as the harms outweigh the benefits.
PSA testing may assist in the diagnosis of prostate cancer for men with symptoms; however, levels may be misrepresentative of disease presence/absence. The effectiveness of DRE is limited
Australian Health Ministers’ Advisory Council, 20107
PSA test is not recommended for a population-based screening program. Individual men may ask their doctors for testing and doctors may recommend it
Cancer Council Australia, 20128
PSA test and DRE offered to men aged 55–69 after they are informed of risks and benefits. Consider testing men aged > 40 with a positive family history
Urological Society of Australia and New Zealand, 20095
Men can be offered a PSA test and a DRE from age 40 as a baseline measure of risk.
Test annually men with PSA levels above the age-related median. Test less frequently men with PSA levels below the median
Royal College of Pathologists of Australia, 20119
Offer a PSA test and DRE, after appropriate counselling regarding the potential risks and benefits, to:
St Vincent’s Prostate Cancer Centre, 200110
Why is there confusion?
The decision whether to test men for prostate cancer is complex. Many people argue that early detection and treatment enables better disease outcomes. This is confounded by the word ‘cancer’ being associated with fear in most people.
Many complicating factors are associated with prostate cancer testing, including:
- insufficient evidence to support routine testing
- variable course of the disease
- limitations of the tests available
- risk of adverse effects associated with treatment.
Current evidence is insufficient to clearly determine whether early detection of prostate cancer through PSA and/or DRE testing reduces cancer mortality. Also, subsequent evaluation and treatment are associated with harms, some of which may be unnecessary.11–14
Evidence from two large, randomised controlled trials demonstrated no or marginal benefit from routine prostate cancer testing.15,16 Early detection of prostate cancer using PSA-based testing marginally reduced the rate of death but was associated with a high risk of overdiagnosis.
The absolute risk difference was 0.71 deaths per 1000 men, which means that 1410 men would need to be tested routinely and an additional 48 cases of prostate cancer would need to be treated to prevent one death from prostate cancer.17
One difficulty with prostate cancer testing is that it may detect asymptomatic cancers that either will not progress or will progress slowly.18 The precise extent to which prostate cancers are overdiagnosed is difficult to determine, but estimates from two large trials suggest 17–30% (ERSPC trial) and 50% (PLCO trial).18
Read more evidence about why PSA is not considered a useful test for routine testing and how it compares with the FOBT for colorectal cancer.
Prostate cancer is characterised by a slow rate of progression compared with most other cancers; in younger men in particular, early detection and treatment would have the potential to offer a survival benefit.
For routine prostate cancer testing to be recommended it would be important to demonstrate a lower risk of death from prostate cancer in those who are tested systematically compared with those who are not. However, this has not been shown with the currently available tests.15,16
Why testing does not have proven benefit
- Many prostate cancers do not require treatment because they grow slowly and do not progress sufficiently to cause harm or symptoms.8
- Prostate cancer is estimated to be present in 30–40% of men aged > 50, but only about one in four of these cancers will result in clinical symptoms and only one in 14 will cause death.8
- The risk of prostate cancer increases with age, and relatively few men will be diagnosed and die from prostate cancer before age 50. The probability of prostate cancer occurring from age 45–49 is 0.9 per 100,000.19
- Risk-adjusted testing is proposed to reduce the number of men tested and treated to save a life by reducing inappropriate testing, but this strategy is not proven to have benefit.20
There are questions about the value of using PSA tests and DRE to test for prostate cancer because of poor specificity and sensitivity. In addition, interpreting PSA test results is difficult.21,22
Increased PSA levels may indicate the presence of prostate cancer but may also result from non-cancerous conditions such as benign prostatic enlargement, urinary tract infections and prostatitis. Most asymptomatic men who have a positive PSA test do not have prostate cancer.
In addition, the PSA test is relatively insensitive, so a negative PSA result does not always correctly exclude the presence of prostate cancer.22
In a large European trial of prostate cancer screening in men aged 50–74, 16% of all PSA tests were declared positive, but three out of four men (aged 55–69) with positive PSA tests did not have prostate cancer on biopsy.16 As discussed below, false-positive results may cause unnecessary physical and psychological harm.
DRE involves manually examining the prostate gland to check for palpable abnormalities. It has low sensitivity, as it is not possible to detect small cancers or to palpate the entire prostate. About 25–35% of the prostate is inaccessible by DRE and so cancers may be missed.23
Combining PSA testing with DRE may improve prostate cancer detection rates compared with either test used alone (although neither is recommended for routine testing).21,24
No tests for prostate cancer have been identified with superior sensitivity or specificity to PSA and DRE. Ongoing research aims to identify new serum markers with greater diagnostic accuracy, particularly for aggressive tumours.25
Prostatic needle biopsies are associated with complications, including:30
- blood in urine and semen
- positive urine cultures
- (rarely) sepsis.
One study reported up to 90% of men with blood in urine and semen after biopsy, and 25% of men reported these effects as a moderate to serious problem.29 Between 2%28 and 7%27 of men are hospitalised because of complications after biopsy, and the associated mortality rate is 0.1%.
Early detection of prostate cancer may also cause harm by exposing some men to unnecessary prostatectomy, which carries substantial risks such as sexual and urinary dysfunction,31,32 if their cancers would never have caused them harm.
Discuss the issues about prostate cancer testing with your patient before requesting a PSA test. Specifically:
- acknowledge the controversy
- summarise the evidence
- explain current guidance
- outline the benefits and harms (Table 2)
- personalise the information for your patient.
One way to personalise the information for your patient is to find out his main concerns about prostate cancer and what is most important to him. Ask questions to determine his views on whether the anticipated benefits of early detection outweigh the risks of testing and treatment. Tailor your discussion to meet those needs, preferences and values.
If a man requests testing for prostate cancer after being fully counselled on the benefits and harms, both PSA and DRE should be performed.3 A man may request prostate cancer testing if he is worried about developing the condition, if he is experiencing symptoms or if he has a family or personal history.
Table 2. Potential benefits and harms associated with prostate cancer testing
Testing can detect prostate cancer early, before it causes symptoms
Elevated PSA levels are not specific to prostate cancer22
Early detection of localised prostate cancer with a biopsy may increase cancer survival
About 80% of PSA results are false positives (at a cut-off level of 2.5–4.0 ng/mL), so a positive PSA test requires a biopsy to confirm diagnosis of prostate cancer and may cause complications11,33
Early detection of advanced prostate cancer increases progression-free survival
Overdiagnosis of indolent prostate cancers is estimated to be 17–50%, and treatment of non-life-threatening cancers can reduce quality of life15,16
- Patient support guide: The early detection of prostate cancer in general practice: supporting patient choice
- Cancer Council Australia
- Australian Institute of Health and Welfare. Cancer in Australia an overview 2012. 2012. http://www.aihw.gov.au/publication-detail/?id=60129542359 (accessed 4 March 2013).
- Smith DP, Supramaniam R, Marshall VR, et al. Prostate cancer and prostate-specific antigen testing in New South Wales. Med J Aust 2008;189:315–8. [PubMed]
- The Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice (the red book). 8th edn. Melbourne: RACGP, 2012. http://www.racgp.org.au/your-practice/guidelines/redbook/
- Gattellari M, Ward JE. Does evidence-based information about screening for prostate cancer enhance consumer decision-making? A randomised controlled trial. J Med Screen 2003;10:27–39. [PubMed]
- Urological society of Australia and New Zealand. Urological society of Australia and New Zealand PSA testing policy 2009. The Society, 2009. http://www.usanz.org.au/uploads/29168/ufiles/USANZ_2009_PSA_Testing_Policy_Final1.pdf (accessed November 2012).
- National Health and Medical Research Council. Testing for prostate cancer using the prostate specific antigen (PSA) test. 2013. http://www.nhmrc.gov.au/your-health/testing-prostate-cancer (accessed.
- Australian Health Ministers' Advisory Council. Prostate cancer screening in Australia: position statement. 2010. http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/other-pop-health (accessed 22 November 2012).
- Cancer Council Australia. National Cancer Prevention Policy: Prostate Cancer. http://wiki.cancer.org.au/prevention/Prostate_cancer/Screening (accessed November 2012).
- Royal College of Pathologists of Australia. Prostate specific antigen testing: age-related interpretation in early prostate cancer detection. 2011. http://www.rcpa.edu.au/static/File/Asset%20library/public%20documents/Policy%20Manual/Position%20Statements/PSA%20Statement.pdf (accessed 29 May 2013).
- St Vincents Prostate Cancer Society. Prostate Cancer Screening. 2012. http://www.prostate.com.au/understanding-diagnosis/ (accessed November 2012).
- Chou R, Croswell JM, Dana T, et al. Screening for prostate cancer: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2011;155:762–71. [PubMed]
- Harris R, Lohr KN. Screening for prostate cancer: an update of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2002;137:917–29. http://annals.org/article.aspx?articleid=742052
- Djulbegovic M, Beyth RJ, Neuberger MM, et al. Screening for prostate cancer: systematic review and meta-analysis of randomised controlled trials. BMJ 2010;341:c4543. [PubMed]
- Ilic D, O'Connor D, Green S, et al. Screening for prostate cancer: an updated Cochrane systematic review. BJU Int 2011;107:882–91. [PubMed]
- Andriole GL, Crawford ED, Grubb RL. Mortality results from a randomized prostate-cancer screening trial. N Engl J Med 2009;360:1310–9. http://www.nejm.org/doi/full/10.1056/NEJMoa0810696
- Schroder FH, Hugosson J, Roobol MJ, et al. Prostate-cancer mortality at 11 years of follow-up. N Engl J Med 2012;366:981–90. [PubMed]
- Schroder FH, Hugosson J, Roobol MJ, et al. Screening and prostate-cancer mortality in a randomized European study. N Engl J Med 2009;360:1320–8. [PubMed]
- Miller AB. New data on prostate-cancer mortality after PSA screening. N Engl J Med 2012;366:1047–8. [PubMed]
- Australian Institute of Health and Welfare. Australian Cancer Incidence and Mortality workbooks. 2012. http://www.aihw.gov.au/acim-books/ (accessed 17 March 2013).
- Stricker PD, Frydenberg M, Kneebone A, et al. Informed prostate cancer risk-adjusted testing: a new paradigm. BJU Int 2012;110 Suppl 4:30–4. [PubMed]
- Catalona WJ, Richie JP, Ahmann FR, et al. Comparison of digital rectal examination and serum prostate specific antigen in the early detection of prostate cancer: results of a multicenter clinical trial of 6,630 men. J Urol 1994;151:1283–90. [PubMed]
- Croswell JM, Kramer BS, Crawford ED. Screening for prostate cancer with PSA testing: current status and future directions. Oncology (Williston Park) 2011;25:452–60, 63. [PubMed]
- U.S. Preventive Services Task Force. The Guide to Clinical Preventive Services 2012. The Task Force, 2012. http://www.ahrq.gov/clinic/pocketgd1011/pocketgd1011.pdf (accessed 12 January 2013).
- Carroll P, Coley C, McLeod D, et al. Prostate-specific antigen best practice policy – part I: early detection and diagnosis of prostate cancer. Urology 2001;57:217–24. [PubMed]
- Tricoli JV, Schoenfeldt M, Conley BA. Detection of prostate cancer and predicting progression: current and future diagnostic markers. Clin Cancer Res 2004;10:3943–53. [PubMed]
- Wilt TJ, Ahmed HU. Prostate cancer screening and the management of clinically localized disease. BMJ 2013;346:f325. [PubMed]
- Loeb S, Carter HB, Berndt SI, et al. Complications after prostate biopsy: data from SEER-Medicare. J Urol 2011;186:1830–4. [PubMed]
- Nam RK, Saskin R, Lee Y, et al. Increasing hospital admission rates for urological complications after transrectal ultrasound guided prostate biopsy. J Urol 2013;189:S12–7; discussion S7–8. [PubMed]
- Rosario DJ, Lane JA, Metcalfe C, et al. Short term outcomes of prostate biopsy in men tested for cancer by prostate specific antigen: prospective evaluation within ProtecT study. BMJ 2012;344:d7894. [PubMed]
- Loeb S, van den Heuvel S, Zhu X, et al. Infectious complications and hospital admissions after prostate biopsy in a European randomized trial. Eur Urol 2012;61:1110–4. [PubMed]
- Litwin MS, Pasta DJ, Yu J, et al. Urinary function and bother after radical prostatectomy or radiation for prostate cancer: a longitudinal, multivariate quality of life analysis from the Cancer of the Prostate Strategic Urologic Research Endeavor. J Urol 2000;164:1973–7. [PubMed]
- Taylor KL, Luta G, Miller AB, et al. Long-term disease-specific functioning among prostate cancer survivors and noncancer controls in the prostate, lung, colorectal, and ovarian cancer screening trial. J Clin Oncol 2012;30:2768–75. [PubMed]
- U.S. Preventive Services Task Force. USPSTF Prostate Cancer Screening Recommendation: what are the benefits and harms of prostate cancer screening? 2012. http://www.uspreventiveservicestaskforce.org/prostatecancerscreening/prostatecancerinfo.pdf (accessed November 2012).