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28 August 2020

Medicare data suggests that up to 21% of Australian men aged 45–74 choose to have a Prostate Specific Antigen (PSA) Test each year, and about 19% of men aged over 74 also undergo testing.

While PSA testing helps to identify men with an increased risk of undiagnosed prostate cancer, and can help to diagnose prostate cancers earlier, it can also produce false positive results, and in some men picks up cancers that are so slow growing that they do not affect a man’s life expectancy, a finding known as over-diagnosis. False positives and over-diagnosis can cause harm, which means men and their doctors need to carefully consider the pros and cons of testing, based on each man’s age and other individual characteristics.

For men with no family history of prostate cancer and no symptoms, the current guidelines recommend that men who decide to undergo regular testing should be offered PSA testing every two years from age 50 to 69.

For men with a family history of prostate cancer who decide to undergo testing, the guidelines recommend men be offered PSA testing every two years from age 40/45 to 69, with the starting age depending on the strength of their family history.

Learn more here > http://psatesting.org.au/info/

What is PSA?

Prostate Specific Antigen (PSA) is a protein made in the prostate gland. The prostate is a walnut-sized gland that sits below the bladder in front of the rectum. It surrounds the urethra, the passage in the penis through which urine and semen pass.

PSA is produced by prostate cells and enters the blood stream. As men get older and the prostate gland grows larger, they can often produce higher levels of PSA. However, higher levels of PSA can also be caused by other conditions. One of these is prostate cancer.

How is PSA measured?

PSA is measured through a simple blood test. The initial PSA test usually measures the total PSA in the blood stream.

Sometimes, if a person has an elevated Total PSA a further test may be ordered that measures two different types of PSA (the amount of PSA bound to protein against the amount of PSA not bound to protein). This is called the free to total PSA ratio.

The free to total ratio can give a hint as to whether the elevated PSA is more likely due to a benign (enlarged prostate) or cancerous cause.

What do the results mean?

A persistently elevated PSA suggests something is going on in the prostate and further tests are required to determine if it is cancer or something else.

If your PSA level is over 3.0 µg/L your PSA test should be repeated within 1 to 3 months, this is because the PSA sometimes returns to normal levels. Your doctor may also order a free to total PSA ratio test. If the PSA is still elevated and the free to total ratio is low, then you may be referred to a specialist (urologist) for more tests.

If you have a family history of prostate cancer and/or are aged in your 40s, your doctor may recommend further PSA testing if your PSA level is above 2.0 µg/L.

What could affect my PSA level?

A ‘normal’ PSA level is different for everyone. It depends on several things, including:

  • your age (the older you are, the higher your PSA level will be).
  • the size of your prostate (levels are higher with an enlarged prostate).
  • your ethnicity.
  • medications you are taking.
  • a urinary infection.
  • certain types of exercise such as bicycle riding or vigorous exercise.
  • how recently you had sex or ejaculated.
  • anal sex or prostate stimulation.

Because the PSA level is related to both normal prostate tissue as well as prostate cancer, there are other conditions that may cause you to have raised PSA levels, such as:

Benign prostatic hyperplasia (BPH) or enlarged prostate: This is a common condition that happens when the prostate grows larger with age. It can affect urination. It is treated with medications or surgery.

Prostatitis (infection or inflammation of the prostate): Prostatitis is when the prostate gland becomes inflamed and sore. It can be very painful and causes more frequent urination. It can be treated with antibiotics, other medications or surgery.

What are the next steps?

Your doctor will consider the results of your repeat PSA test, as well as your age and family history before recommending the next steps for you.

If your repeat PSA results are not cause for concern, you will be offered PSA testing every two years.

If your repeat PSA results still indicate a concern, your doctor will refer you to a urologist for further investigations.

Visiting the urologist

The urologist will likely perform a Digital Rectal Examination (DRE). This is a procedure where a doctor inserts a gloved, lubricated finger into the rectum to feel the size and shape of the prostate gland. A normal DRE result does not necessarily rule out prostate cancer.

If the DRE and/or your PSA tests indicate a possibility of prostate cancer, the next steps can include an MRI scan and/or a tissue biopsy.

Magnetic Resonance Imaging (MRI) is a scan to assess the prostate size and look for any abnormal areas. An MRI is used to determine if a cancer is present and which part of the prostate it can be found in. This helps the urologist to decide whether a biopsy is needed and which area of the prostate to target for the biopsy. An MRI is performed as an outpatient procedure, so you do not need to be admitted to a hospital.

A biopsy is when multiple small samples of tissue are removed from the prostate to be examined in the laboratory. This will show whether the cells in the prostate are malignant (cancerous) or benign (non-cancerous). A biopsy is the only way a firm tissue diagnosis of prostate cancer can be made.

If the biopsy is negative, you will probably be offered regular check-ups with more PSA tests to monitor you in the future. If subsequent tests show a rise in PSA levels, you may need another biopsy or MRI scan

What if it’s prostate cancer?

A positive biopsy is the only way to confirm that you have prostate cancer. The cancer grade, which is determined from the biopsy, gives an indication of how fast the cancer is growing.

You may be required to have further tests to determine the stage of the cancer. The cancer stage indicates whether the cancer has remained within the prostate gland or has spread outside of the prostate to surrounding areas or other parts of the body.

How your prostate cancer is treated will depend on your PSA results, the grade and stage of the cancer, your symptoms, your overall health and your personal preferences.

If there is a low risk that your prostate cancer will cause you harm, you may be offered Active Surveillance. This involves regular testing to check for any changes to the cancer. If the cancer changes you may need treatment. 

If your cancer is higher risk, you will be offered treatment. Different treatments come with differing side effect some of which include urinary problems, erectile dysfunction, bowel problems, fatigue, depression and anxiety.

You may need to meet with several different cancer specialists such as a urologist, radiation oncologist and/or medical oncologist to discuss your treatment options with you.

Points worth remembering

  • Taking your partner, family member or a close friend with you when you see your doctor can be helpful when discussing your diagnosis and treatment options with your specialist.
  • 95% of men with prostate cancer are alive 5 years after diagnosis, 91% are alive 10 years after diagnosis and many will live a lot longer.
  • An abnormal PSA result does not necessarily mean you have prostate cancer.
  • In very rare cases, men can have prostate cancer even if their PSA test result is normal – talk to you doctor if you notice any worrying symptoms.

Do the Guidelines need review?

PCFA has written to the Commonwealth Government to seek funding support for a five-year review and update of the PSA Test Guidelines, on the basis that the current guidelines remain highly controversial and poorly understood by the majority of Australians.

Recent research has found that about 75% of Australians do not know the guidelines, an alarmingly high level of unawareness that discourages early detection and decreases population-wide survival outcomes.

There is little doubt of an association between confusion concerning early detection and generally low levels of awareness of prostate cancer in the Australian context, an association confirmed in a recent report by the Prostate Cancer Patient Coalition of the Asia Pacific, which found that 70% of Australian men do not know the symptoms of prostate cancer and 67% of Australian men have unmet needs for information on prostate cancer prior to their diagnosis, saying they wished they had known more about it.

Moreover, prostate cancer treatment has changed markedly over the past five years, with significant advances in clinical care and a drastic reduction in rates of overdiagnosis and overtreatment. It is therefore timely for us to undertake a comprehensive review of the guidelines and consider the emerging evidence on prostate cancer screening, incidence, and survival in the Australian context. 

Investment in a revised set of PSA Test Guidelines and increased public awareness activity holds great potential for improving prostate cancer awareness and survival in Australia.

Where can I get more information?

Visit PCFA for information and support at www.prostate.org.au/support/ or call on 1800 22 00 99.