Experts take major step towards maximising benefits and minimising harms from prostate cancer testing

Draft guidelines for Australia released at World Cancer Congress

2014 World Cancer Congress. Melbourne, Australia: Leading Australian cancer agencies are seeking community and professional input into draft clinical practice guidelines aimed at maximising the benefits and minimising the harms of use of the Prostate Specific Antigen (PSA) test for prostate cancer.

Released today for public consultation, the Australian draft guidelines have been developed by a broad based Expert Advisory Panel, which included general practitioners, public health experts, urologists, pathologists and allied health professionals. This is the first time globally that an expert advisory panel with all key stakeholders and varying perspectives has come together for the development of draft guidelines focused on PSA testing. Cancer Council Australia’s guidelines unit undertook the required evidence reviews and coordinated expert input into guideline drafting with funding from Prostate Cancer Foundation of Australia (PCFA).

The draft guidelines are now available on a wiki platform for the public consultation process. Representative draft recommendations include:

For men without a prostate cancer diagnosis or symptoms that might indicate prostate cancer

  • For men informed of the benefits and harms of screening who wish to undergo regular testing, offer PSA testing every two years from age 50 to age 69, and offer further investigation if the PSA is greater than 3.0 ng/mL.
  • In asymptomatic men interested in undergoing testing for early diagnosis of prostate cancer, digital rectal examination is not recommended as a routine test in the primary care setting.
  • Do not offer PSA testing to a man who is unlikely to live another seven years.
  • Offer evidence-based decisional support to men considering whether or not to have a PSA test, including the opportunity to discuss the potential benefits and risks of PSA testing before the decision to test is confirmed.

For men undergoing an initial prostate biopsy

  • Take 21–24 cores in initial biopsies for the diagnosis of prostate cancer. In addition to the sextant biopsies, direct 15–18 additional biopsies to the peripheral zones of the prostate.

Active Surveillance and Watchful Waiting

  • Offer active surveillance to men with prostate cancer who meet all the following criteria: – PSA ≤ 20 ng/mL, clinical stage T1-2 and Gleason score 6.
  • Advise men with potentially curable prostate cancer considering watchful waiting that their risk of developing more advanced prostate cancer and dying from it will be higher with watchful waiting than with immediate definitive treatment but that, in the medium to long term, watchful waiting is unlikely to diminish their wellbeing and quality of life.

According to the Expert Advisory Panel Chair, Emeritus Professor Villis Marshall AC, the lack of consensus on PSA testing confuses men and their health advisers. Notwithstanding the confusion, every year about 20 percent of Australian men aged 45 to 74 have a PSA test.

“Prostate cancer is the second most common cause of cancer deaths in Australian men and the fourth most common cause of men’s deaths overall. We simply cannot afford to ignore this important health issue,” said Professor Marshall AC.

“These are draft guidelines and the committee welcomes and encourages submissions through the consultation process. They have been developed according to the National Health and Medical Research Council procedures and requirements. Following the consultation phase, the draft guidelines will be submitted to NHMRC for approval.”

Panel member and leading cancer epidemiologist Emeritus Professor Bruce Armstrong AM said the draft guidelines did not recommend a national screening program, in keeping with health policy worldwide.

“The draft guidelines are intended to inform the interactions between men and their doctors, when a man might request a PSA test or his doctor might offer one,” said Professor Armstrong AM.

“The guidelines are intended to provide clarity and help men and their doctors to make better informed choices about prostate cancer testing based on the latest available evidence.”

PCFA and Cancer Council Australia jointly sponsored and facilitated the process.

“We are delighted to be working with all the stakeholders in such a collaborative way on such an important public health project – it’s all about building consensus,” said PCFA CEO, Associate Professor Anthony Lowe.

Cancer Council Australia emphasised the importance of clarity for Australian men and their doctors.

CEO of Cancer Council Australia, Professor Ian Olver, said the PSA test was not accurate enough for population screening yet it remained in widespread use.

“So it’s important to assist patients and practitioners with guidelines that could help maximise the benefits of the test and minimise the harms,” Professor Olver said.

Professor Mark Frydenberg, who is Head of Urology at Monash Medical Centre and Vice President of the Urological Society of Australia and New Zealand, said the new recommendations will help to improve the outcomes derived from prostate cancer testing in the future.

“These draft recommendations will help define which men specifically will benefit the most from testing. Once finalised they will provide clarity about age brackets and how we deal with different types and stages of prostate cancers in different circumstances,” said Professor Frydenberg.

The Union of International Cancer Control (UICC) welcomed the draft guidelines and has commended the collaborative approach taken by PCFA, Cancer Council Australia and leading experts.

“We applaud this initiative internationally as a leading example in the development of guidelines of this kind. We encourage other countries to consider this truly multi-sectoral approach as a model that could be adapted to their own settings,” said UICC President, Professor Mary Gospodarowicz.

Approximately 22,000 Australian men are diagnosed with prostate cancer annually, joining close to 120,000 Australian men who are already living with the disease. Close to 3,300 Australian men will die each year of prostate cancer, and every man has a one in five chance of being diagnosed with prostate cancer by the time they are 85[i]

Health professionals and the public are invited to review and comment on the draft guidelines at