Guidelines for preventive activities in general practice

The Red Book
9.1 Prostate cancer

Age range chart
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	70-79	>80
Not recommended as a preventive activity

Screening of asymptomatic (low-risk) men for prostate cancer by prostate specific antigen (PSA) testing is not recommended because the benefits have not clearly been shown to outweigh the harms.¹ This remains the case following recent large trials.¹ Therefore, GPs have no obligation to offer prostate cancer screening to asymptomatic men.

Some men may have individual concerns about prostate cancer and may put a higher value on the possible benefits of prostate cancer screening. This requires specific discussion to address the benefits and harms (from overdiagnosis and overtreatment) of prostate cancer screening.² The Royal Australian College of General Practitioners (RACGP) has produced a patient decision aid that may assist this discussion

If after an informed process, perhaps using a decision aid, a man still requests prostate cancer screening, a PSA blood test is acceptable.³ Digital rectal examination (DRE) is no longer recommended as it is insufficiently sensitive to detect prostate cancers early enough.⁴

Clinicians should not test for asymptomatic prostate cancer (eg by adding the PSA test to a battery of other tests) without counselling about possible harms as well as possible benefits, and obtaining informed consent.

Men with one or more first-degree relatives diagnosed <65 years of age
Men with a first-degree relative with familial breast cancer (BRCA1 or BRCA2)

Table 9.1.1. Prostate cancer: Identifying risk
Who is at risk?	What should be done?	How often?
Average risk
The risk of developing prostate cancer increases with age and positive family history. However, because prostate cancer is normally slow growing, men aged >75 years or with a life expectancy of <10 years are at reduced threat of dying from a diagnosis of prostate cancer Men with uncomplicated lower urinary tract symptoms (LUTS) do not appear to have an increased risk of prostate cancer. The most common cause of LUTS is benign prostate enlargement. Early prostate cancer often does not have symptoms	Respond to requests for screening by informing patients of risks and benefits of screening using a decision support aid (I, A)	On demand (Practice Point) ^5, 6
High risk
		Respond to requests for screening by informing patients of risks and benefits of screening (Practice Point)	On demand (Practice Point) ^5–7
LUTS, lower urinary tract symptoms

Table 9.1.2. Screening for prostate cancer in asymptomatic men
Not recommended	Justification
Prostate specific antigen (PSA) screening	The most common adverse effect of radical prostatectomy is erectile dysfunction, which affects most men (it is less common in younger men, those with a lower PSA, and when nerve-sparing surgical techniques are used) ^4, 8–11 Other complications are common as well, including urinary incontinence (which is very common in the months after treatment; however, this returns to normal in 75–90% men after two years, depending on treatment type). To a lesser extent, urinary irritation and bowel symptoms can occur. General feelings of ‘vitality’ are lost in about 10% of men ¹² Both suicide and cardiovascular disease (CVD) increase enormously (eight and 11 times more respectively) in the week after men are given their diagnosis of prostate cancer ^13, 14 Even diagnostic procedures performed following positive screening can be harmful, with Australian data showing that the risk of life-threatening sepsis needing intensive care admission is about 1% after biopsy ¹⁵ Despite large trials, two meta-analysis suggests that prostate cancer screening does not save lives For more information on benefits and harms, visit the Clinical practice guidelines PSA testing and early management of test-detected prostate cancer ^2, 8
ACR, albumin-to-creatinine ratio; CKD, chronic kidney disease; CKD-EPI, Chronic Kidney Disease Epidemiology Collaboration; CVD, cardiovascular disease; PSA, prostate specific antigen; eGFR, estimated glomerular filtration rate; UACR, urine albumin-to-creatinine ratio, CVD, cardiovascular disease;

Implementation

Strategy

Patients who request testing should be informed about the risks and benefits of tests for prostate cancer, and should be assisted to make their own decision using an acceptable decision aid.¹⁶

References

Cancer Council Australia. Community Care and Population Health Principal Committee of the Australian Health Ministers’ Advisory Council ; NHMRC summary of the evidence. Sydney: Cancer Council Australia, 2014.
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.
National Health and Medical Research Council. PSA testing for prostate cancer in asymptomatic men. Information for health practitioners. Canberra: NHMRC, 2014.
Lim LS, Sherin K, ACPM Prevention Practice Committee. Screening for prostate cancer in US men: ACPM position statement on preventive practice. Am J Prev Med 2008;34(2):164–70.
Bruner DW, Moore D, Parlanti A, Dorgan J, Engstrom P. Relative risk of prostate cancer for men with affected relatives: Systematic review and meta-analysis. Int J Cancer 2003;107(5):797–803.
Johns LE, Houlston RS. A systematic review and meta-analysis of familial prostate cancer risk. BJU Int 2003;91(9):789–94.
Zeegers MP, Jellema A, Ostrer H. Empiric risk of prostate carcinoma for relatives of patients with prostate carcinoma: A meta-analysis. Cancer 2003;97(8):1894–903.
Ilic D, O’Connor D, Green S, Wilt TJ. Screening for prostate cancer: An updated Cochrane systematic review. BJU Int 2011;107(6):882–91.
Ilic D, Neuberger MM, Djulbegovic M, Dahm P. Screening for prostate cancer. Cochrane Database Syst Rev 2013;1:CD004720.
Moyer on behalf of US Preventive Services Task Force. Screening for prostate cancer: US Preventive Services Task Force Recommendation Statement. Ann Intern Med 2012;157(2):120–34.
Alemozaffar M, Regan MM, Cooperberg MR, et al. Prediction of erectile function following treatment for prostate cancer. JAMA 2011;306(11):1204–14.
Sanda MG, Dunn RL, Michalski J, et al. Quality of life and satisfaction with outcome among prostate-cancer survivors. N Engl J Med 2008;358(12):1250–61.
Fang F, Keating NL, Mucci LA, et al. Immediate risk of suicide and cardiovascular death after a prostate cancer diagnosis: Cohort study in the United States. J Natl Cancer Inst 2010;102(5):307–14.
Fall K, Fang F, Mucci LA, et al. Immediate risk for cardiovascular events and suicide following a prostate cancer diagnosis: Prospective cohort study. PLoS Med 2009;6(12):e1000197.
Bowden FJ, Roberts J, Collignon PJ. Prostate cancer screening and bacteraemia (letter). Med J Aust 2008;188(1):60.
Gattellari M, Ward J. Does evidence-based information about screening for prostate cancer enhance consumer decision-making? A randomised controlled trial. J Med Screening 2003;10:27–29.