Draft guidelines for the early detection of prostate cancer released this week recommend proactively offering PSA testing to males aged 50-69 every two years, a significant change from previous 2016 guidelines, which implied discussions over PSA testing should be initiated by the patient.

The draft clinical practice guidelines were developed by a multidisciplinary team including urologists, GPs, radiation oncologists and other experts, as well as patients. They have been released for feedback by the Prostate Cancer Foundation of Australia.

Experts involved say the balance of benefits and harms has shifted substantially in the intervening years, as MRIs have become standard practice to investigate elevated PSA tests, and active surveillance has become widely accepted.

“Evidence suggests up to 89% of Australian men now undergo prebiopsy multiparametric MRI and the proportion of men with low-risk prostate cancer opting for active surveillance has increased from 66% in 2015 to 80% in 2021,” the draft guidelines state.

Associate Professor Jeremy Grummet, a urological surgeon and director of urology at Alfred Health, chaired the MRI section of the draft guidelines, and was previously a member of the European Prostate Cancer Guidelines Panel.

He says the new guidelines are long overdue, as urologists have been routinely using prostate MRI for at least five years now, dramatically reducing the number of invasive procedures performed.

“It allows us to triage who gets a biopsy, and we know from the best evidence and systematic reviews and meta-analyses, that you can reduce the number of unnecessary prostate biopsies by half when MRI is the next test after an elevated PSA,” Associate Professor Grummet explains.

“The other beauty of MRI is that, generally speaking, when it’s positive, you can only see the more aggressive types of prostate cancer,” he says.

“You can’t see the low-grade, indolent versions, which is perfect because they’re exactly the ones we don’t want to detect, because they’re the ones that lead to over-diagnosis and, in some cases, over-treatment.”

“So there was a real mismatch between our old guidelines and what standard clinical practice has been in Australia for the last five years.”

MRIs have to be ordered by a urologist in order to get the Medicare rebate, he notes, but the associated reduction in risk changes the balance of pros and cons for offering PSA testing.

“It really strengthens the argument for a more structured PSA testing program to solve the problem of inequity,” Associate Professor Grummet says.

“Because ever since PSA was introduced in Australia and, in fact, in every other country, the PSA testing has been opportunistic. In other words, it’s been random.”

This has meant health literate men are more likely to discuss the test with their doctor and make an informed choice, he notes.

PCFA National Director and Chair of the Expert Advisory Panel, Adjunct Professor Peter Heathcote, agrees.

“These recommendations reflect international best practice and take us one step closer to a nationally organised approach to early detection. This will move us away from an inconsistent, discretionary model to one that gives men and their doctors clear, evidence-based advice.”

Key recommendations include:

• A strong recommendation for GPs to initiate conversations about PSA testing and offer two-yearly testing to all men aged 50–69. If total PSA is 3.0 µg/L or greater repeat the test within 1-3 months, and, if confirmed, offer referral for further investigation.
• Offer a baseline PSA test to interested men from age 40.
• A reversal of the 2016 stance against testing men over 70, recommending testing based on clinical assessment.
• Earlier and more frequent testing for men at higher risk, including those with a family history or of sub-Saharan ancestry, as well as Aboriginal and Torres Strait Islander men, starting at age 40.
• Reinforcing that digital rectal examinations are no longer recommended in primary care.
•  Multiparametric MRI is now the preferred diagnostic test after raised PSA, to determine if biopsy is needed.

The draft guidelines are two years in the making so far. The consultation period closes on Friday 25 May, with the final version expected in August.