12 July 2021

Older Aussies at risk over high PSA uptake

Cancer Clinical Men

Older Australian men may be at risk of unnecessary and possibly harmful treatment following inappropriate prostate cancer screening, according to an analysis of general practice data.

Contrary to guideline recommendations, the study of 180 Victorian practices found that as many as half of older asymptomatic men had a potentially unnecessary PSA test.

Researchers from Macquarie University and Outcome Health looked at the PSA testing rates of asymptomatic men over age 40 over a three-year period between 2016 and 2018.

A 2013 NHMRC evaluation of the research found that, despite its widespread use, there was no clear evidence that performing a PSA on men without symptoms reduced their risk of prostate cancer or early death.

It noted that performing the tests on asymptomatic men did carry the potential risks of overdiagnosis and overtreatment.

Current guidelines from the Cancer Council of Australia and the Prostate Cancer Foundation of Australia say that asymptomatic men who have been informed about the risks and benefits can be offered the screening test biennially between the ages of 50 and 69.

The researchers found that the proportion of men who had at least one test over the study period increased with age, peaking at around 50% in those aged 65-69.

Men aged 70-74 were most likely to have been tested twice over the three-year duration of the study, with almost one in two having at least two tests in that time.

The average PSA level rose with age, from a median of 0.7ng/mL in men aged 40–44 to 1.9ng/mL in men aged 85 years or more.

Researchers found that the proportion of men tested more than once within 24 months increased with age. Median PSA levels also increased with age, so for men over 69 years of age, this could lead to further invasive tests and treatments, some of which may be unnecessary or may cause harm.

This is the most comprehensive picture of PSA testing in asymptomatic men in Australia since the latest guidelines were released, the authors said.

“Why patterns of testing are different to those recommended (i.e., more frequently than biennial and beyond 69 years of age) cannot be explained by general practice data, but reasons may include patient expectations, fragmentation of care and the persistence of old guideline recommendations.”

MJA 2021, online July 12

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13 Comments on "Older Aussies at risk over high PSA uptake"

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Raymond Yeow
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Raymond Yeow
3 months 6 days ago

“2013 NHMRC evaluation of the noted that performing the tests on asymptomatic men did carry the potential risks of overdiagnosis and overtreatment….”
BUT
From Saturday 17th July:
LGA of the City of Fairfield residents who work in other LGAs must be tested for COVID-19 every three days, even if they do not have symptoms

Workers from across Greater Sydney who work at locations more than 50km from the outer boundary of the Shellharbour, Wollongong, Wollondilly, Blue Mountains, Hawkesbury and Central Coast LGAs must be tested for COVID-19 every seven days, even if they do not have symptoms

Dr Ross
Guest
Dr Ross
3 months 8 days ago
This is total rubbish in my view and experience. Wait for symptoms before testing is going to just detect advanced metastatic disease. Personally i was symptom free and no family history, my psa jumped 5 times since previous test. I had Gleason 9 stage 5 tumour at 68 years age! Luckily non invasive new PET & MRI studies showed no met disease but significant prostate activity -22mm diameter tumour not felt on DRE!. Only then was a TP Bx performed with minimal S/e’s confirmed diagnosis and staging. Radical prostatectomy confirmed original diagnosis and treated the ca. Hopefully I remain disease… Read more »
Ian Rivlin
Member
Ian Rivlin
3 months 8 days ago

I wonder how many authors, who advocate “watchful waiting”, “laisser-faire” and similarly impotent and lazy management options have seen someone die of metastatic prostate cancer?

Cloistered in an office (or laboratory) and surrounded by a plethora of statistic crunching computers, researchers often lose sight of there being a living, feeling human being at the centre of this unnecessary debacle.
Test, test, test. Information is power.
Ignorance isn’t bliss.

Madoc Schlencker
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Madoc Schlencker
3 months 8 days ago

The evaluation of the research was done in 2013.
Since then, there has been more work with combining PSA with free to total PSA, serial samples and DRE if PSA is abnormal, and looking at PSA velocity.
Given the emerging testing methodology, perhaps the guidelines need to be reviewed.

Dr Ross
Guest
Dr Ross
3 months 8 days ago

DRE by my UG surgeon failed to detect my 22mm tumour. If 2-3 sequential psa are rising rapidly then MRI should be the next set! My ratio was 17+ % so don’t hang your hat on that either.
If my UGS failed to have ordered the mri then probably my Gleason 9 tumour would have been Metastatic if i then waited until symptomatic or 2 yrs for next psa.

Justin Coleman
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Justin Coleman
3 months 8 days ago
To counter some of your statements, Peter Bradley: “What new research?” This is indeed new research. It was published just yesterday, and is newer today than almost any other PSA research. “Promoted purely as a cost saving measure”. Most guidelines around the world, worked on by hundreds of practising clinicians, have come up with similar conclusions – this is not a government conspiracy. The RACGP guidelines, for example, have no vested interest in cost saving. “PSA is not an expensive test”. No, nor are a hundred other tests we could decide to do on everyone, but decide not to –… Read more »
Madoc Schlencker
Guest
Madoc Schlencker
3 months 8 days ago

From what I can see, this study is talking about PSA screening, and not about what best guidelines are. This study is a good study, and obviously highlights either that GPs know the guidelines and disagree, that they don’t know the guidelines, or that they are having very meaningful conversations with their patients, and their patients are choosing to undertake the test anyway.
Either way, we can all agree that more needs to be done in this area.

Peter Bradley
Member
Peter Bradley
3 months 8 days ago
I think you, in your hast to support the ‘party line’ Justin, are the one missing the point. Otherwise explain the headline in todays Courier Mail stating…””Too many men over 70 who have no symptoms are being tested according to new research.” Surely that is the point. That they are still suggesting screening asymptomatic men is a waste of time, and may even be harmful, when most of us who know a bit about this subject are painfully aware that by the time it becomes ‘symptomatic’ the horse has often bolted. So this so-called new study, based on quite old… Read more »
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