Guidelines for preventive activities in general practice

Cancer

Prostate cancer

      1. Prostate cancer

Cancer | Prostate cancer

Shared decision making age bar in the general population

0-9 10-14 15-19 20-24 25-29 30-34 35-39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 ≥80

Prostate cancer is the most commonly diagnosed cancer in Australian men with an estimated 25,500 new cases in 2023, with around one in seven eventually dying of prostate cancer. It is the third commonest cause of cancer deaths in men (estimated 3743 deaths from prostate cancer in 2023).1,2 

National population screening for prostate cancer is not recommended in Australia, nor in the United States or Europe. Instead, Australian and international guidelines emphasise the need for men to be given the opportunity to discuss the potential benefits and harms of prostate-specific antigen (PSA) testing before deciding whether to be tested. Despite advances in diagnostic techniques, the risk of overdiagnosis remains substantial and may lead to treatment for men who may never have become symptomatic in their lifetime.3 

Box 1. Identifying risk of prostate cancer3

Risk level Average Moderate
Increased risk of 2.5–3-fold of death due to prostate cancer
High
At least 8–10-fold increased risk of death due to prostate cancer
 
Definition Men without family history Men with a brother or multiple first-degree relatives diagnosed with prostate cancer
 
Men with three affected first-degree relatives diagnosed with prostate cancer
 
 
 
 

Screening

Recommendation Grade How often References
GPs should not order a prostate-specific antigen (PSA) test for men unless they provide informed consent for screening. Practice point N/A 4
Offer men the opportunity to discuss the potential benefits and harms of PSA testing as a screening test for prostate cancer. Evidence-based decision support tools can assist in this discussion. Practice point N/A 3
For men aged 50–69 years at average* risk of prostate cancer who have been informed of the benefits and harms of testing and who decide to undergo regular testing for prostate cancer, offer PSA testing every 2 years, and offer further investigation if total PSA is greater than 3.0 ng/mL. Conditionally recommended Every two years 3
For men at moderately raised risk* of prostate cancer due to family history, offer testing every 2 years from age 45 to 69 years. Conditionally recommended Every two years 3
For men at high risk* of prostate cancer due to family history, offer testing every 2 years from age 40 to 69 years. Conditionally recommended Every two years 3
For men aged 50–69 years with initial total PSA >3.0 ng/mL, offer repeat PSA within 1–3 months. For those with initial total PSA >3.0 ng/mL and up to 5.5 ng/mL, measure free-to-total PSA percentage at the same time as repeating the total PSA. Practice point N/A 3
Advise men aged ≥70 years who have been informed of the benefits and harms of testing and who wish to start or continue regular testing that the harms of PSA testing may be greater than the benefits of testing in men of their age. Practice point N/A 3
*Refer to Box 1. Identifying risk of prostate cancer.

Case finding

Recommendation Grade How often References
PSA testing in men who are likely to live less than another 7 years is not recommended (as any mortality benefit from early diagnosis of prostate cancer due to PSA testing is not seen within less than 6–7 years from testing). Testing not recommended (strong) N/A 3
Digital rectal examination is not recommended as a routine addition to PSA testing in asymptomatic men interested in undergoing testing for early diagnosis of prostate cancer. Testing not recommended (strong) N/A 3

The use of decision aids is recommended to help men make an informed choice about PSA testing. The RACGP is updating its Should I have prostate cancer screening? decision aid to assist this discussion between GPs and their patients.

Longer term follow-up from the large European Randomized study of Screening for Prostate Cancer (ERSPC) trial has provided new estimates of benefit from PSA testing with a number needed to screen of 246 to prevent one prostate cancer death at 21 years’ follow-up.5 

Changes in urological practice, including use of multiparametric magnetic resonance imaging (MRI), transperineal biopsy and active surveillance for low-risk prostate cancer aim to reduce the harms of overdiagnosis and overtreatment from PSA testing. Multiparametric MRI is more accurate at diagnosing clinically significant prostate cancers than trans-rectal ultrasound-guided biopsy and is recommended in international guidelines as the next step along the diagnostic assessment in men with raised PSA.6,7 This approach reduces the proportion of men with a raised PSA who require biopsy and exposure to the potential harms of the procedure, and also reduces the diagnosis of clinically insignificant disease.

While there are no specific recommendations for Aboriginal and Torres Strait Islander peoples, evidence suggests that while there are lower rates of prostate cancer among Aboriginal and Torres Strait Islander people, they may experience differences in treatment and mortality in comparison to non-Aboriginal men. While further research is required to explain these differences, ongoing monitoring and efforts are needed to ensure Aboriginal and Torres Strait Islander men have equitable access to best practice care.

Refer to the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people, Chapter 15: Prevention and early detection of cancer – Early detection of prostate cancer.

Men of African ancestry are at increased risk of prostate cancer but neither Australian nor US guidelines make specific recommendations about PSA testing in this population.3,4 This increased risk should be considered as part of shared decision making.

  1. Australian Institute of Health and Welfare. Cancer. AIHW, 2022 [Accessed 19 May 2023].
  2. Australian Institute of Health and Welfare. Cancer data in Australia: Prostate cancer – Projection method changes, updated long-term prostate cancer incidence projection. AIHW, 2023 [Accessed 18 October 2023]
  3. Prostate Cancer Foundation of Australia; Cancer Council Australia. PSA testing and early management of test-detected prostate cancer: Clinical practice guidelines. Cancer Council Australia [Accessed 23 May 2023].
  4. US Preventive Services Task Force. Prostate cancer: Screening. Final recommendation statement. USPSTF, 2018 [Accessed 7 April 2024].
  5. de Vos II, Meertens A, Hogenhout R, Remmers S, Roobol MJ; ERSPC Rotterdam Study Group. A detailed evaluation of the effect of prostate-specific antigen-based screening on morbidity and mortality of prostate cancer: 21-year follow-up results of the Rotterdam Section of the European Randomised Study of Screening for Prostate Cancer. Eur Urol 2023;84(4):426–34. doi: 10.1016/j.eururo.2023.03.016.
  6. European Association of Urology; European Association of Nuclear Medicine; European Society for Radiotherapy & Oncology; European Society of Urogenital Radiology; International Society of Urological Pathology; International Society of Geriatric Oncology. EAU–EANM–ESTRO–ESUR–ISUP–SIOG guidelines on prostate cancer. EAU, 2024 [Accessed 7 April 2024].
  7. National Institute for Health Care and Excellence. Prostate cancer: Diagnosis and management. NICE guideline (NG131). NICE, 2019, update 2021 [Accessed 7 April 2024].
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