Few areas of medicine have attracted more controversy than prostate cancer screening (PSA) and early intervention in prostate cancer. Much of this followed two landmark trials (PLCO and ERSPC) that did not show a significant mortality benefit for PSA screening.
Not only was PSA screening ineffective, but in that era, many patients underwent radical treatment for non-aggressive cancers. With a combination of poor efficacy and overtreatment, it was unsurprising that a ‘backlash’ against PSA screening ensued. The RACGP Red Book incorporates these issues – effectively counselling against PSA screening.
However, prostate cancer is the most common cancer in Australian men and the second most common cause of cancer death. Despite high prevalence and significant lethality, prostate cancer trajectory is usually measured in decades. Hence follow-up of the original PSA screening trials (median nine years) was actually too short to properly assess for an impact on mortality.
With follow-up to 13 years and, most recently (in the Rotterdam subset) 19 years, a significant impact of PSA screening on death rates can be seen. Based on a CISNET analysis, PSA screening reduces prostate cancer mortality by 25-35%, comparable to colorectal and breast cancer screening.
Morbidity of Biopsy. Traditional prostate cancer diagnosis revolved around a transrectal biopsy for an elevated PSA. However, following the PROMIS and PRECISION trials, elevated PSAs are a trigger for an MRI – not a biopsy. Moreover, when a biopsy is performed, it may be targeted (reducing the number of needles) and many practitioners have shifted to a transperineal approach (with a much lower risk of infection).
Overtreatment. The possibility of overtreatment is a concern, but largely historical. In the modern era of accurate stratification, improved diagnostics and MDT-led management, men do not undergo treatment for indolent disease. One US study indicates a tripling in conservative management between 2005 and 2015. Our experience would be similar.
Morbidity of Treatment. Prostate cancer treatment has a bad reputation due to concerns about inaccuracy/side effects (radiation) or incontinence/impotence (surgery). Modern radical prostatectomy has undergone significant evolution. Excellent results for continence and (to a lesser extent) potency are typical. Surgical expertise is paramount, but what happens outside the operating theatre is equally critical. High-volume surgeons will therefore work with a team of prostate cancer specialist nurses, physiotherapists, sexual medicine practitioners, and senior urology nurses.
National guidelines on PSA screening have been published by the Prostate Cancer Foundation of Austrlaia and endorsed by the RACGP. A PSA test may be done every two years from ages 50 to 69. Referral should be considered if the PSA is above 95th percentile, or more than 3.0ng/mL (2.0ng/mL in high risk groups). To reduce false positives and assist with Medicare criteria, a patient should have an MSU and two PSAs with free total ratio (minimum a month apart) before referral.
- PSA screening is now supported by national guidelines.
- An MRI should always be done before a biopsy.
- Technical expertise and multidisciplinary teamwork are key to the best surgical results.
References available on request.
Questions? Contact the editor.
Author competing interests: None to disclose.
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