Why is prostate cancer testing so confusing?

Prostate cancer testing

Prostate cancer testing in Australia is up for review again. The current Guidelines were released in January 2016. According to the Prostate Cancer Foundation Australia (PCFA) (a key player in developing the Guidelines):-

We developed the guidelines in order to resolve the controversy surrounding PSA testing for both men and their doctors. The guidelines do not recommend a population screening program for prostate cancer (a program that offers testing to all men of a certain age group) as evidence does not support such a program.

For men who decide to be tested it contains guidance on matters such as what age to start testing; how frequently to be tested; when to stop testing; the PSA level which should prompt further investigation; family history; and the role of the digital rectal examination.

Unfortunately, the “controversy” has not been resolved by these Guidelines.  Another thing that has not been resolved is the ongoing confusion in the community (men and their partners) about the whole testing thing. So, let’s take a look at some of the confusion, disagreement, misconceptions and myths.

Leading medical bodies not on the same page

Urologists generally understand the importance of testing. The Urological Society of Australian and New Zealand (USANZ) is the peak membership organisation for urological surgeons in Australia and New Zealand. Their latest Position Statement (issued in September 2022) addresses the elephant in the room:-

PSA testing guidelines were created by the Prostate Cancer Foundation of Australia (PCFA) and the Cancer Council of Australia. They were endorsed by a number of organisations including the National Health and Medical Research Council (NHMRC), the Royal Australian College of General Practitioners (RACGP) and the Urological Society of Australia and New Zealand (USANZ) in November 2015. 

The guidelines recommend offering PSA testing from age 50 to informed men (that is, men who have been informed of the risks and benefits of testing) who wish to be tested for prostate cancer. These recommendations however are not reflected in the 9th Edition RACGP Red Book.

The Royal Australian College of General Practitioners (RACGP) is “the professional body for general practitioners in Australia. The RACGP is responsible for maintaining standards for quality clinical practice, education and training, and research in Australian general practice”.

The RACGP publishes a Red Book (their guidelines on preventative practice for all Australian GPs). The current edition (9th) states that “GPs have no obligation to offer prostate cancer screening to asymptomatic men”.

Wow. That’s an interesting statement!

Bearing all of that in mind, let’s take a look at some of the myths or misconceptions about prostate cancer testing.

Before we do, though, keep in mind one of Alan’s favourite sayings:-

Diagnosing prostate cancer is a bit like putting a jigsaw together – each individual test forms part of the overall picture.

Drawing of orange-coloured jigsaw puzzle pieces fitting together. Each piece is labelled with something relating to diagnosing prostate cancer.
The Prostate Cancer Diagnosis Puzzle

Myth # 1

Prostate cancer testing means a DRE (digital rectal examination – finger up the bottom).

Nope, not necessarily. The most common test for prostate issues is a simple blood test. It’s called a PSA test and it’s like the first piece of that jigsaw puzzle.

Many GPs will not perform a DRE. The RACGP’s Red Book says:- “Digital rectal examination (DRE) is no longer recommended as it is insufficiently sensitive to detect prostate cancers early enough.”

So, why is that DRE test used? Well, it is one of those important puzzle pieces. We also like the explanation in favour of DRE found on Dr Phillip Stricker’s website:-

Around 25% of cancers detected in a screening program will have a PSA of less than 4. The cancers in these patients will only be picked up by a finger examination of the prostate (DRE) so it is important to have both the PSA test and the rectal examinations.

If one does not actively search for the cancer before symptoms begin then the vast majority of cancers detected at the time of diagnoses are incurable. Screening is the process to find cancer at an early potentially curable stage before symptoms have commenced.

Another urologist, Dr Jamie Reynolds, offers the following comments about the continued value of the dreaded DRE:-

A DRE can give an estimate of the size of the prostate and also indicate whether there are any irregularities in the prostate gland (e.g. nodules). Not all prostate cancers though can be felt on DRE. A small percentage of prostate cancers do not secrete PSA, and so a DRE is an important part of detecting some prostate cancers.

Basically, the finger-up-the-bum test allows the doctor (or urologist) to check the size, shape and texture of the prostate gland. The DRE may help detect an enlarged prostate or a suspicious lump that might need further investigation. It might also pick up rectal tumours!

Myth # 2

My PSA test results show high PSA, so I must have prostate cancer.

Again, not necessarily.

What is PSA? The Cancer Council NSW describes it like this:-

Prostate specific antigen (PSA) is a protein made by both normal prostate cells and cancerous prostate cells. PSA is found in the blood and can be measured with a blood test. The test results will show the level of PSA in your blood as nanograms of PSA per millilitre (ng/mL) of blood.

There is not one normal PSA level for everyone. If your PSA level is above 3 ng/mL (called the threshold), this may be a sign of prostate cancer. Younger people or people with a family history of prostate cancer may have a lower threshold. PSA levels can vary from day to day. If your PSA is higher than expected, your GP will usually repeat the test to help work out your risk of prostate cancer.

Your PSA level can be raised even when you don’t have cancer. Other common causes of raised PSA levels include benign prostate hyperplasia, recent sexual activity, an infection in the prostate, or a recent digital rectal examination. Some people with prostate cancer have normal PSA levels for their age range.

The blood test used to measure PSA levels is only part of the jigsaw puzzle (just like Alan says).

The best way to think about a PSA test is to look at it as an indicator of possible changes in your prostate gland. Not all changes will be cancer. Knowing your regular PSA levels gives you a chance to watch for any unusual behaviour.

If your PSA levels are high, there are quite a few possible causes apart from cancer. Higher levels might be due to:-

  • An infection in the prostate (such as prostatitis)
  • BPH (Benign Prostatic Hyperplasia – a non-cancerous condition that can cause urinary issues)
  • Stimulation of your prostate in the days immediately before your blood test, such as having sex, vigorous bike-riding, or having a DRE and then having a blood test
  • Your prostate gland may be naturally larger than the “normal” size range, so it will pump out a greater volume

Always discuss your results with your GP and ask for a copy for your own records.

It can be helpful to keep a chart to show how your PSA levels are tracking over time. A simple spreadsheet can clearly show any movement in the levels.

Another test that is far less common is called “free-to-total PSA”. Again, this is a blood test and it can be conducted at the same time as the regular PSA test. The Cancer Council NSW describes it as:-

This test measures the ratio of free PSA to total PSA in your blood. Free PSA is PSA that is not attached to other blood proteins. This test may be suggested if your PSA level is between 4–10 ng/mL and your doctor is not sure whether you need a biopsy. A low free-to-total PSA ratio may be a sign of prostate cancer.

In Alan’s case, his standard PSA results would not have suggested prostate cancer. Fortunately, he was also getting free-to-total testing and those results revealed a different picture altogether.

Alan’s PSA levels were really low, but his free-to-total test showed that he needed to see his urologist for further investigation. When the urologist did a DRE on Alan, he discovered that the prostate gland felt firm, so a biopsy was arranged.

We thank our lucky stars that Alan pushed his GP to order both PSA tests – his outcome otherwise might not have been so rosy. Just another piece of that jigsaw puzzle!

Myth # 3

Prostate cancer is just a disease for old blokes.

Wrong. Younger men can get prostate cancer.

According to the Prostate Cancer Foundation Australia (PCFA):-

… a male’s chance of being diagnosed with prostate cancer increases with his age.

Of the 24,217 Australian males expected to be diagnosed with prostate cancer this year, 422 (1.74%) will be under 49 years of age, 3,124 (12.9%) will be 50-59 years of age and 8,890 (36.7%) will be 60-69 years of age, 8,571 will be aged 70-79 (35.39%), and 3,210 will be over the age of 80 (13.25%).

In fact, younger men who are diagnosed with prostate cancer can turn out to have worse outcomes. For example:-

Prostate cancer is generally a slow growing disease. However in some cases, particular younger men, the high grade disease spreads aggressively and can be lethal.

A major problem is that prostate cancer at an early (potentially curable) stage usually does not have obvious symptoms.

According to the Man Up website:-

There is increasing evidence suggesting a baseline PSA at the age of 40 has the potential to predict an individual’s future risk of developing prostate cancer. It can then guide the frequency of further testing with a PSA and DRE.

Individuals identified as high risk can undergo close monitoring whilst individuals identified as low risk can have less frequent monitoring. It also allows the identification of a small number of aggressive cancers that can be found in young men.

Myth # 4

Prostate cancer screening is a waste of money as it does not save enough lives.

We totally disagree with this shocking argument!

This concept forms the underlying reason for so much disagreement within the medical community and public health authorities across the world.

Here are a couple of our responses to that argument:-

  • How many lives saved is “enough”?
  • What about the major cost to the medical system of treating men with advanced, metastatic prostate cancer?
  • What about quality of life?

By the way, “screening” is the wrong word to use for prostate cancer testing in Australia. Australians are “screened” for bowel cancer, breast cancer and cervical cancer. Men have to ask their GP to order a PSA blood test if they wish to know about the health of their prostate gland. Some GPs in Australia have been known to refuse to order the test!

“Survivorship” is the buzz word these days. Thanks to developments in prostate cancer treatment and (especially) early diagnosis, more men are surviving prostate cancer. Alan is a great example of this – since his radical prostatectomy in 2011, he has not required any further intervention for his prostate cancer. He still gets his PSA tests every year and keeps a beady eye on them. He is one of the lucky ones.

Men who are diagnosed after their prostate cancer has already “escaped” from the prostate gland tend to have a far worse treatment outcome. This is where the argument about quality of life really kicks in. Early diagnosis gives men the chance to have their cancer treated before it gets out of the gland and into their bones, lymph nodes, etc.

We argue that encouraging men to get regular prostate cancer tests will save lives, save money and save many men from suffering the terrible side-effects of advanced prostate cancer treatment.

Myth # 5

Getting a PSA test can cause men harm.

Really? Not in our view.

Men are supposed to be the stronger sex, the tougher one. Men are far more likely to be sent to war than women. Men (especially younger men) tend to engage in more aggressive behaviour and participate in higher risk activities. So why is there so much concern about a simple blood test causing “harm” to men? And what exactly is this “harm”?

According to the RACGP’s Prostate Screening Information Sheet for patients:-

There is significant debate about prostate cancer screening. This is because many prostate cancers that are detected are low risk (the slow growing type) and would never have caused harm to the man, but testing for and treating these cancers can cause harm.

This is where the argument about over-diagnosis and over-treatment arises. One of the so-called harms of PSA testing is the stress potentially caused to men from worrying about the results of their test. If men are diagnosed with prostate cancer, yet their cancer is still in the low-risk category, critics of testing claim that these men run the risk of “over-treatment”.

Side-effects from standard prostate cancer treatment are definitely not desirable (losing control of your bladder and problems with erections – see our posts on these topics). In the past, it was more common for men with “low-risk” prostate cancer to undergo immediate treatments like surgery or radiotherapy.

In 2022, it is more likely that men diagnosed with “low-risk” prostate cancer will be placed on “active surveillance”, which aims to monitor their cancer until it reaches a more aggressive state. Better diagnostic and monitoring equipment, coupled with early diagnosis, can lead to fewer men ending up on chemotherapy for advanced prostate cancer. I’d say that was a far better outcome than failing to be tested and finding out about your cancer when it could no longer be successfully cured.

So, the harm of knowing that you have prostate cancer when it is in an early stage versus the harm of not knowing until your treatment options are actually “management” options and your cancer has spread throughout your body. For us, it’s a no-brainer.

Why bother getting regular prostate cancer checks?

It’s like looking after your car. You wouldn’t drive around in a car that had bald tyres, faulty brakes, dodgy exhaust and cracks in the windscreen. Our parts don’t last forever without attention.

Poster showing diagram of man's body like a car

Just consider Spanner Man – your prostate check is just one part of your overall health monitoring. Make yourself a promise to get a full health “service” every year, and include your PSA (and free-to-total PSA). Because you’re worth it, right!