Prostate Cancer
Prostate cancer is the most common cancer among Australian men. It is estimated that in 2019 there will be 19,000 new cases in Australia and 3,500 deaths from the disease. Newly diagnosed patients have a 95% relative survival at five years with early stage diagnosis being beneficial.
Screening
PSA testing for prostate cancer was introduced to Australia in the late 1980s, resulting in increased incidence (86/100,000 males in 1988 to 184/ 100,000 in 1994). These new cases were typically low grade disease and a decline in mortality was observed (44/100,000 in 1993, 35/100,000 in 1999). Approximately 80% of men treated for prostate cancer will experience negative effects such as urinary incontinence or erectile dysfunction.
Practice recommendations
In Australia RACGP guidelines do not recommend routine PSA screening. NHMRC guidelines (2016) recommend that the risks and benefits of PSA screening are discussed with men who can then make an informed decision; but do not recommend a population screening program. The UK national screening committee (2016) recommended against a systematic screening program and the US preventive services taskforce (2018) recommended that information about the benefits and harms of PSA testing are provided to patients. The European Association of Urology (2019) advocates for structured PSA screening using individualised screening intervals.
Evidence limitations
The evidence basis for PSA screening comes from five randomised controlled trials. All trials have been conducted outside of Australia and some show low compliance rates and high contamination. A further obstacle to interpreting these trials is time. Prostate cancer has a long natural history, with mortality outcomes typically occurring after 15+ years. As follow-up time increases, the benefits of screening grow while treatment options and triaging tools improve.
Conclusions
Current evidence supports a benefit for PSA testing, particularly in the context of individualised screening intervals.