The RACGP has endorsed new guidelines on prostate cancer screening, putting to bed the idea that GPs and urologists are at odds over PSA testing.

GPs are now asked to start a conversation about PSA testing in all male patients aged 50-69 years, as well as higher-risk 45-year-olds.

Moreover, from age 45 any man who requests a PSA should be offered one regardless of risk, according to the guideline, which was endorsed by the NHMRC.

This includes 45-year-old men who aren’t higher risk but are “interested in their prostate health”, and those over age 70 depending on a clinical assessment that considers their comorbidities and whether their life expectancy exceeds seven years.

Recommendations for every stage of early investigation have had a facelift since the previous 2016 guidelines, according to the chair of the Guideline Expert Advisory Panel, Brisbane urologist Adjunct Professor Peter Heathcote.

“Modern prostate cancer diagnosis is no longer based on a PSA blood test alone,” the past president of the Urological Society of Australia and New Zealand said in a statement.

“Today’s diagnostic pathway incorporates individual risk assessment, shared decision-making, multiparametric MRI before biopsy, targeted biopsy techniques and active surveillance for men with low-risk disease.”

The balance of risks and benefits has changed

Associate Professor Mark Morgan, chair of the College’s Expert Committee for Quality Care, said the College’s input into and endorsement of the guidelines was “testimony to the fact that we’re actually all working on the same page.”

Widespread screening with PSA tests has been controversial, with debate over whether the potential benefit of catching prostate cancer early outweighed the risks from biopsies and treatment in men who may not suffer from the cancer in their lifetimes.

“I think that we’re much closer aligned than we’ve ever been before,” said Associate Professor Morgan, professor of general practice at Bond University.

A major change in the debate is that, in recent years, the potential harms of PSA testing have declined, he said.

Clinicians now better understand who is most at risk of prostate cancer morbidity and mortality, and have less invasive management strategies when prostate cancer is identified.

“That has changed the balance of benefits and harms to make it a much more nuanced discussion with men, but one that we’ve got clearer information about,” Associate Professor Morgan said.

For example, a positive PSA test no longer means men immediately undertake a transrectal biopsy that might lead to impotence and urinary incontinence. The guidelines now recommend first doing a non-invasive multiparametric MRI, and doing a transperineal biopsy if the imaging is suspicious of cancer or there is still clinical concern.

“It’s not an inevitability that you’ll end up with a biopsy, and not an inevitability that if you have a biopsy of cancer, you’re going to end up with some treatment that could render you incontinent or impotent. Now it’s much clearer that people with a slow-growing cancer can avoid some of those harms from treatment,” Associate Professor Morgan said.

New definitions

One of the most relevant updates for GPs was the guidelines’ clarification of risk, he added.

The guidelines define “higher risk” as those with twice the risk of prostate cancer compared with the overall Australian male population, and includes men with a significant family history, Black men of sub-Saharan African ancestry and those with a confirmed BRCA2 gene mutation.

The guidelines also solidify and refine the steps to take after an elevated PSA result, illustrated in a clear flowchart.

This was important to be aware of and communicate as part of patient counselling, Associate Professor Morgan said.

The federal government has given the RACGP $320,000 to help implement the guidelines within general practice. It is expected to update the Red Book and decision aids to bring them into close alignment with the guidelines, as well as developing educational resources for continuing professional development.

Recommendations

The guidelines conditionally recommend that men aged between 50 and 69 get tested every two years, if they choose to after a discussion of the possible risks and benefits. This was downgraded from a “strong” recommendation in the draft guidelines.

Men with a lower risk who have a PSA of at least 3 μg/L should have a repeat test within 1-3 months and referred to a specialist if they have a second elevated result.

For men who are at higher risk, a PSA of 2 μg/L or more should trigger another test within 1-3 months.

Similarly, higher risk men aged 45-49 should get retested if their PSA is 1 μg/L or more. If their result is less than 1 μg/L, they don’t need PSA testing again until age 50.

“That is a real sign of safety, that your chance of developing significant prostate cancer before the age of 50 is exceedingly low, and therefore you don’t need a further test until you hit 50,” said Professor Jeremy Grummet, Director of Urology at Alfred Health in Melbourne.

“We all know in practice that the PSA can vary in one individual patient over time. And if we just do a one-off PSA, it might be a blip, it might be an aberration,” the Monash University Professor told Healthed.

Men aged 70 and older can continue to be tested every two years, if they decide to after a discussion of possible benefits and harms. In addition, doctors should do a clinical assessment that includes patient preferences, comorbidities and a life expectancy of more than seven years.

The threshold for men over age 70 is 5.5 μg/L, and if they have a result under that limit they can stop further testing.

For men who have two elevated PSA results, the next step is a multiparametric MRI.

“From a Medicare reimbursement point of view, which is very important for most of our patients, you need to actually have the second elevated PSA within that 1-3 month bracket,” Professor Grummet said.

Rectal exams are no longer recommended as a routine addition to PSA testing within primary care, but may be done by urologists and other specialists before a biopsy is undertaken

People diagnosed with low grade prostate cancer, even some low-intermediate risk, can be managed with active surveillance, which means monitoring every 6-12 months.

“So we’ve got MRIs preventing over-diagnosis, and we’ve got active surveillance preventing over-treatment. Two huge changes,” Professor Grummet said.

Moreover, biopsies have improved too – they’re now going via the skin rather than rectally, which significantly reduces the risk of sepsis and other side effects, he said.

Aboriginal and Torres Strait Islander men are a priority population in the guidelines, but have the same testing recommendations as other men.

Professor Jeff Dunn AO, Chair of the Guideline Steering Committee, said these guidelines were a “watershed moment” in our country’s approach to prostate cancer.

The process was lengthy, spanning three rounds of public consultation over the two years of development, and synthesising more than 1,100 research papers and 27,000 scientific abstracts.

“Much has changed over the past decade. The evidence has matured, diagnostic technologies have advanced, and clinical practice has evolved substantially,” he said.

Prostate cancer kills almost 4000 Australians each year, making it the second most common cause of cancer death in Australian men and a top 10 cause of premature death.