New prostate cancer screening guidelines are here

Prostate specific antigen (PSA) testing can now be offered to men aged 45-49, to be repeated within a couple of months if the results are considered high.

While standard PSA testing is recommended every two years for those aged 50-69 and where appropriate for those aged 70 and above. Previously guidelines excluded those over 70.

It is hoped that lowering the screening age may help detect prostate cancer earlier in those considered at high risk of the disease.

Prostate cancer is Australia’s most commonly diagnosed cancer with around 29,000 men expected to be diagnosed this year. Some 4000 are expected to die from the disease.

The guidelines, put together by the Prostate Cancer Foundation of Australia (PCFA) to replace the 2016 guidelines, put a greater emphasis on shared decision making and risk assessment to detect clinically significant prostate cancer earlier while reducing unnecessary tests and treatment.

PCFA said the guidelines position Australia among the world's first countries to transition from an informal model of discretionary testing to a planned, evidence-based approach to opportunistic early detection.

New screening age recommendations for prostate cancer. Source: PCFA

The new guidelines confirm the importance of GPs initiating discussions about prostate cancer and PSA testing with patients, rather than the onus being on patients.

They state that informed discussion of the possible benefits and harms of PSA testing with shared decision making and patient choice is key to good clinical practice.

Updated recommendations across every stage of early detection form part of the guidelines, including risk assessment, PSA testing, use of multiparametric MRI before biopsy, active surveillance and care for priority populations.

They also strengthen recommendations for men with significant family history, inherited genetic risk and other groups at increased risk of developing clinically significant prostate cancer.

Fremantle-based GP and the RACGP representative on the guideline’s project steering committee Dr Brett Montgomery said the guidelines better reflect best clinical practice in how prostate cancer is diagnosed.

He told Medical Forum a lot of the changes focused on what urologists do once a patient with a high PSA test is referred.

“At the time of the last guidelines, a biopsy would often be the next step and often that would be done with a needle passing through the patient’s rectum into the prostate,” he said.

“These days the first step that urologists normally take is an MRI scan to get a sense of how likely it is that cancer is present in the prostate gland.

“This saves probably about half of the men who would otherwise have had a biopsy from needing to have a biopsy. This reduces complications, expense and unpleasantness for the patient.

“It also reduces overdiagnosis – the discovery of mild disease that otherwise would not have gone on to affect their life.

“Nowadays urologists tend to do their biopsy with a needle through the perineal skin rather than the rectum, which is a longer but cleaner journey to the prostate gland and there’s fewer infective complications.”

Once these steps have been taken, if cancer is discovered, treatment options also vary.

Dr Montgomery said there is increasing confidence amongst urologists in managing lower grade cancer with active surveillance rather than surgery – ongoing MRI, plus or minus biopsy, increasingly sparing men with mild disease from operations that can have other side effects.

“Although our efforts to detect prostate cancer may not be saving more lives now than the process was 10 years ago, we’re doing it with less harm, less unnecessary diagnoses, less side effects from biopsies and the overall benefit to risk ratio has got better,” he said.

Adjunct Professor Peter Heathcote, chair of the guideline expert advisory panel, said modern prostate cancer diagnosis is no longer based on PSA blood tests alone.

“Today's diagnostic pathway incorporates individual risk assessment, shared decision-making, multiparametric MRI before biopsy, targeted biopsy techniques, and active surveillance for men with low-risk disease,” he said.

“These advances allow clinicians to identify clinically significant cancers more accurately while reducing unnecessary biopsies, significantly reducing risks of overtreatment, and ensuring we protect men’s quality of life while managing individual risks.”

Prior to the release of these guidelines, the RACGP raised concerns about a suggestion for Aboriginal and Torres Strait Islander men to be screened from the age of 40, warning of the risks of overdiagnosis and harm to this group.

This concern was addressed and the guidelines now outline that PSA testing recommendations for Aboriginal and Torres Strait Islander men are the same as for the general population.

PCFA chief executive Anne Savage said the next step was ensuring the guidelines were put into clinical practice.

“Evidence only saves lives when it reaches the men who need it. Australian men need to understand their individual risk, know when to have the conversation with their GP, and be supported by clinicians with access to the latest evidence,” she said.

“These guidelines provide Australia with an extraordinary opportunity to reduce deaths from our most commonly diagnosed cancer. Realising that opportunity will require coordinated implementation, clinician education, consumer awareness, and ongoing investment in evidence-based care."