National Guide

Chapter 19 | Cancer prevention and early detection

Prostate cancer







National Guide to preventive healthcare for Aboriginal and <br/>Torres Strait Islander people
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      6. Prostate cancer

Cancer | Prostate cancer

Dr Jonathan Gillies 

Key messages

  • Prostate cancer is the most common cancer in Aboriginal and Torres Strait Islander men.1
  • Increasing age and a family history of prostate cancer, particularly in a first-degree relative (biological brother or father), are the main risk factors for developing prostate cancer.2
  • There is no national screening program for prostate cancer because current evidence does not support age-based screening of average-risk people in the population.
  • The prostate-specific antigen (PSA) test is the only test currently recommended in primary care to assess an individual man’s potential prostate cancer risk. Although the PSA test can help detect prostate cancers earlier, it can also lead to overdiagnosis and unnecessary, harmful overtreatment.3
  • Updated national clinical practice guidelines for the use of the PSA test are currently in development, with the project overseen by a project steering committee that includes Aboriginal and Torres Strait Islander representation and a plan for Aboriginal and Torres Strait Islander stakeholder consultation.
  • The decision to take a PSA test should be made by an individual patient in consultation with their doctor based on an informed discussion of the possible benefits and harms of the test.4
  • Clinicians should be aware of highly gender-sensitive cultural practices for many Aboriginal and Torres Strait Islander people and that discussions about the prostate need to be culturally appropriate and respectful of men’s business.5
Type of preventive activity - Screening
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
Men aged under 70 years at average risk (no family history of prostate cancer) Do not routinely recommend PSA testing N/A Strong International and national guidelines6–8 Evidence of harm and no clear evidence of benefits in this age group in men at average risk
Men aged 50–69 years at average risk (no family history of prostate cancer) who are fully informed, understand the benefits and harms of testing and wish to undergo regular testing Offer testing and further investigation if PSA >3.0 ng/mL Every two years Conditional National guidelines6,9 If the man has a preference for screening and is aware of potential risks of a PSA test, standard screening recommendations may be followed
Men aged 40–69 years at increased risk (eg a first-degree family member with cancer diagnosed at age <60 years) who wish to undergo regular testing Conditionally recommend PSA testing Every two years

If initial PSA ≤75th percentile for age, no further testing until age 50 years

If PSA in the 75th–95th percentile for age, reconfirm the offer of testing every two years

If PSA ≥95th percentile for age, offer further investigation.		 Conditional National guidelines6,9 Conditional recommendation for PSA screening for men at an increased risk of prostate cancer, where earlier detection of prostate cancer may reduce morbidity and mortality
Men aged 70 years and over Do not routinely recommend PSA testing N/A Good practice point National guidelines6,9 Minimal morbidity or mortality benefit in this age group and the harms of PSA testing may be greater than the benefits of testing in men of their age
Any man unlikely to live more than another seven years at any life stage Do not recommend PSA testing N/A Strong National guidelines6,9 No evidence of mortality benefit from screening until at least seven years after PSA testing began10
  • If a man has elected to undergo PSA testing, set up a recall/reminder to rescreen at an appropriate time interval (eg every two years).
  • Primary healthcare clinics and services should consider cultural, structural and individual barriers to effective care, including culturally appropriate approaches to prostate cancer education and discussion, and recognition of gender-diverse people (LGBTQIA) and their individual healthcare needs.

Clinical guidelines

Patient resources

Background

Prostate cancer is the most diagnosed cancer for Aboriginal and Torres Strait Islander men, with an age-standardised incidence rate of 108 new cases per 100,000 men.1 This incidence rate is lower than the 151 new cases per 100,000 men for non-Indigenous Australian men. However, the five-year survival rate is lower among Aboriginal and Torres Strait Islander than non-Indigenous Australian men (86% versus 92%, respectively).1

Prostate cancer age-specific incidence and mortality rates for all men increase with each life stage, increasing rapidly after age 50 years.1,2 As well as advancing age, factors that increase an individual’s risk of developing prostate cancer include a family history of prostate cancer (the risk is at least doubled with a biological brother or father diagnosed with prostate cancer before the age of 60 years) or a family history of breast or ovarian cancer (especially BRCA1 and BRCA2 gene mutations).2

For the general population, age-standardised prostate cancer mortality in Australia fell significantly between 1998 and 2021 (from 37.8 to 21.7 per 100,000 population),11 whereas PSA testing rates also declined.12 This may suggest improvement in targeted diagnosis and treatment. The reasons for the disparity in mortality rates between Aboriginal and Torres Strait Islander and non-Indigenous Australian men are not well understood. On the limited evidence available, variations in access to and engagement with the health system are a likely reason for the differences in prostate cancer outcomes.5,13

There is no national screening program for prostate cancer in Australia. The evidence does not currently support either digital rectal examination (DRE) or PSA blood test as population screening tools.4 In an asymptomatic man (ie no symptoms that could indicate a problem with the prostate), the choice to test for prostate cancer risk needs to be made as a shared decision between the clinician and patient.4

PSA testing is the primary method available for assessing an individual man’s risk of prostate cancer. Current clinical practice guidelines in Australia9 and internationally7,8 recommend offering evidence-based decisional support for men considering whether to have a PSA test. Decisional support is a discussion taking into account individual risk, such as age and family history (where this is known), and the harms and benefits of screening, given the limitations (including high false-positive rates) of PSA testing,9,14 noting that for a man with symptoms suggestive of a possible prostate issue (eg frequency of urination, poor urine stream, blood in the semen or urine, pain on urination or ejaculation or back or pelvic pain), a PSA test and other investigations are recommended.4

The main harm reported with PSA tests for screening is false-positive results leading to over investigation (eg additional blood tests, DRE, magnetic resonance imaging [MRI] and/or biopsy), overdiagnosis (where prostate cancer is detected but would never have caused significant harm in the person’s lifetime), harm from investigations and treatments (including bleeding, infection, incontinence and erectile dysfunction/impotence) and anxiety.4 These potential risks should be weighed against the potential for early detection of a potentially harmful cancer before it spreads, and possible early treatment and/or cure of prostate cancer.4

In primary care, DRE is not recommended as a standalone examination or as a routine addition to PSA.9 This is because a significant volume of cancer needs to be present before a DRE can detect an abnormality. DRE is also associated with patient reluctance and wide variation in how DRE is performed by clinicians.9 A DRE remains an important examination in the specialist setting and in the examination of a symptomatic man.9

Improved access to diagnostic and imaging services, such as MRI, before an invasive biopsy is undertaken can help reduce the harms of overtreatment. Many men with low-risk disease, identified through PSA testing of asymptomatic men, are good candidates for active surveillance. Active surveillance is a management approach of routine tests and monitoring (PSA tests, biopsy and MRI) that is designed to postpone or avoid radical treatment until it is deemed clinically necessary. Active surveillance is a safer way to manage men, avoiding many of the common side effects of surgery or radiation therapy.15

For men who decide to have prostate cancer screening, the general recommendation is to have a PSA blood test every two years from age 50 to 69 years. For men in whom the risk of prostate cancer is higher than average (eg with a biological father, brother or son diagnosed with prostate cancer), regular testing can start earlier, from age 40 or 45 years,.4,9 These recommendations may change when new Prostate Cancer Foundation of Australia and Cancer Council Australia guidelines are published (expected late 2024). The key will be informed, consultative decision making based on the health profile and circumstances of the individual patient.

Considerations for all Aboriginal and Torres Strait Islander men who decide to be tested include a family history of prostate cancer, what age to start testing, how frequently to be tested and when to stop testing, as well as a threshold PSA level to prompt further investigation and/or urology referral.

 


 
  1. Australian Institute of Health and Welfare (AIHW). Cancer in Aboriginal & Torres Strait Islander people of Australia. AIHW, 2018 [Accessed 15 May 2024].
  2. Cancer Council. Understanding prostate cancer. Cancer Council, 2022 [Accessed 15 May 2024].
  3. Australian Health Ministers’ Advisory Council, Cancer Council Australia. Prostate cancer screening in Australia: Position statement. Australian Health Ministers’ Advisory Council, 2014 [Accessed 15 May 2024].
  4. Prostate Cancer Foundation of Australia. Should I have a PSA test? Prostate Cancer Foundation of Australia, 2023 [Accessed 15 May 2024].
  5. Adams M, Gleeson K, Supramaniam R, Earnshaw T. Engaging Aboriginal and Torres Strait Islander communities in prostate cancer health care programs. Prostate Cancer Foundation of Australia, 2015 [Accessed 15 May 2024].
  6. The Royal Australian College of General Practitioners (RACGP). Preventive activities prior to pregnancy. In: Guidelines for preventive activities in general practice. 9th edn. RACGP, 2018 [Accessed 15 May 2024].
  7. Office for Health Improvement & Disparities. Advising men without symptoms of prostate disease who ask about the PSA test. UK Government, 2022 [Accessed 15 May 2024].
  8. Grossman DC, Curry SJ, Owens DK, et al. Screening for prostate cancer: US Preventive Services Task Force recommendation statement. JAMA 2018;319(18):1901–13. doi: 10.1001/jama.2018.3710.
  9. Prostate Cancer Foundation of Australia, Cancer Council Australia. Clinical practice guidelines: PSA testing and early management of test-detected prostate cancer. Prostate Cancer Foundation of Australia, 2015 [Accessed 15 May 2024].
  10. Schröder FH, Hugosson J, Roobol MJ, et al. Prostate-cancer mortality at 11 years of follow-up. N Engl J Med 2012;366(11):981–90. doi: 10.1056/NEJMoa1113135.
  11. Australian Institute of Health and Welfare (AIHW). Cancer data in Australia. AIHW, 2023 [Accessed 15 May 2024].
  12. Luo Q, Yu XQ, Kahn C, et al. Changes in prostate cancer incidence, mortality and survival in relation to prostate specific antigen testing in New South Wales, Australia. Cancer Epidemiol 2022;78:102159. doi: 10.1016/j.canep.2022.102159.
  13. Navin Richards J. Engaging Aboriginal and Torres Strait Islander males. Healthy Male (Andrology Australia), 2013 [Accessed 15 May 2024].
  14. Thompson IM, Tangen CM, Goodman PJ, et al. Finasteride improves the sensitivity of digital rectal examination for prostate cancer detection. J Urol 2007;177(5):1749–52. doi: 10.1016/j.juro.2007.01.071.
  15. Tse T, Wu B, Vagholkar S, Willcock S. Shared decision making in prostate cancer screening: An update. Aust J Gen Pract 2023;52(3):99–101. doi: 10.31128/AJGP-07-22-6498.




 

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