There are urgent calls to overhaul the way general practitioners test for prostate cancer, amid concerns too many men are dying unnecessarily.
- Prostate is the most commonly diagnosed type of cancer in Australia
- Routine screening is not recommended for most men because of the risks of overdiagnosis
- However, some doctors believe guidelines are outdated and need to change
Routine prostate cancer screening is not recommended for most men, but some specialists are calling for changes to testing guidelines.
"There are patients that are angry, that are dying and had a delayed diagnosis," says Peter Swindle, a urologist who specialises in prostate cancer.
Data from the Australian Institute for Health and Welfare (AIHW) shows prostate cancer has overtaken breast cancer as the most common type of cancer in Australia, with an estimated 24,217 cases recorded this year alone.
This year, more than 3,500 men are expected to die from the disease and in the six years to 2020, there was a 15.6 per cent increase in prostate cancer deaths, according to the AIHW.
Some men have told the ABC they have struggled to get a doctor to regularly screen them for the disease.
One of those is Justin Falkiner, a police acting inspector who lives in the regional New South Wales town of Dubbo.
He has a family history of the disease: His father has it, as did his late grandfather.
So, when he was 36, his GP ran a prostate-specific antigen blood test, known as a PSA.
The test measures a patient's PSA level: If it's too high for the person's age, the patient will undergo further testing — usually scans or a biopsy — to determine if they have prostate cancer, or non-cancerous conditions such as an infection or inflammation of the prostate.
Mr Falkiner's test came back in the low range.
When he was in his early 40s, he asked his GP to repeat the test but was told guidelines stated it would not be necessary until he was 50.
"So, silly me, I didn't ask for a second opinion."
Prostate cancer can run in families, suggesting a genetic link.
According to the American Cancer Society, having a father or brother with prostate cancer more than doubles a man's risk of developing the disease.
'Devastating' diagnosis after chance test
Mr Falkiner returned two years later for an unrelated matter and, after his GP ran full bloods, his PSA came back with a reading of 21. Typically, if a PSA reading is above three, it should be repeated within three months.
He was referred to a urologist and when the test was repeated a month later, his PSA had risen sharply to 27.
"At that point, my urologist pressed the panic button," he said.
He was diagnosed with stage 2 prostate cancer, which was deemed an intermediate risk — where cancer is likely to grow faster and be mildly to moderately aggressive.
"Everyone has this opinion, 'It won't happen to me.' I was no different," he said.
"So … whilst I might have been prepared for what I was going to be told, it was still devastating to hear those three words."
Also weighing on his mind was his family: his wife, Kristin, and their young children, Joshua and Ava.
Given the rapid increase in his PSA level, Mr Falkiner's urologist feared his cancer might have already spread to other parts of the body — which would have made his treatment and survival much more difficult. Luckily, that had not occurred.
But his specialist was sure of one thing: "He said to me, basically, had I left this to 50, we'd be not only dealing with a different diagnosis but a very different outcome."
Why prostate screening is a contentious issue
Screening for prostate cancer is a contentious area because of the risk of overdiagnosis, and potentially "risky" treatments, says Jon Emery, the Herman professor of primary care cancer research at the University of Melbourne.
"Overdiagnosis really means that it picks up prostate cancers that are relatively slow growing and that would have never caused any harm to a man if they'd never known about it," Professor Emery said.
"The forms of biopsy that historically we used, which went through the passage through the rectum, have the potential to cause harm.
"Then [there are] harms of treating the cancers as well … particularly erectile dysfunction and urinary incontinence."
That, he said, meant doctors had to weigh up the risks and benefits of treating a cancer that, potentially, may have never posed a problem if left untreated.
However, Dr Swindle argues modern technology prevents many of those harms, and MRIs reduce the number of unnecessary biopsies.
"In the past, men with insignificant cancer were being treated 30 to 40 per cent of the time. That's now down to 6 per cent in Australia," he said.
But concerns around overdiagnosis of prostate cancer have influenced how GPs do PSA testing and Dr Swindle worries some diagnosis is now happening too late.
"I would estimate that somewhere between 60 to 70 per cent of my patients get to me with a delayed diagnosis, where they could have been potentially picked up between one and three years earlier," he said.
Conflicting guidelines for doctors
In Australia, there are two main sets of guidelines used by doctors: those produced by the Royal Australian College of General Practitioners (RACGP), the professional body for GPs in Australia, and those by the National Health and Medical Research Council (NHMRC), a government-funded expert body which develops health advice.
The RACGP is currently reviewing its guidelines, though any update is unlikely to be published until next year.
"Unfortunately, the RACGP Red Book, which is the Bible for GPs, is in stark contrast to the NHMRC testing guidelines," Dr Swindle said.
"As a result, there is confusion amongst the GP community and GPs don't know whether they should test men or not."
RACGP guidelines (source)
NHMRC guidelines (source)
Screening of asymptomatic (low-risk) men by PSA testing is not recommended because the benefits have not clearly been shown to outweigh the harms
Men who are at average risk of prostate cancer should be offered PSA testing every 2 years from age 50 to 69
For men with average risk of prostate cancer: Respond to requests for screening by informing patients of risks and benefits before proceeding
Men who have a father or one brother who has been diagnosed with prostate cancer should be offered PSA testing every 2 years from age 45 to 69
For high-risk (have one or more first-degree relatives diagnosed with prostate cancer under 65, or familial breast cancer) patients: Respond to requests for screening by informing patients of risks and benefits before proceeding
Men who have a father and two or more brothers who have been diagnosed with prostate cancer should be offered PSA testing every 2 years from age 40 to 69
Dr Swindle wants the RACGP to provide its members with better education on how to conduct prostate cancer screening using PSA testing, and to adhere to the NHMRC guidelines.
He also wants pathology companies to follow those guidelines.
However, Karen Price, the RACGP's president, does not accept the criticisms being levelled at the college.
"Urologists already had the benefit of the triage that's been performed by general practitioners," she said.
"We see a large proportion of asymptomatic men and we have to make that very difficult and challenging conversation with them about what the risks and harms are."
Dr Price said changes to the guidelines, to be unveiled next year, would be guided by peer-reviewed evidence.
"We're trying to assess that screening may be of benefit for many more men than we thought because the risks of harms of diagnosis might be less," she said.
"But that has to be really looked at very closely … by scientists who can really crunch the numbers and the stats and look at all the available evidence coming out in the international literature."
The recommendations are likely to include increased surveillance of low-risk prostate cancer patients.
Prostate cancer group also calls for new guidelines
The Prostate Cancer Foundation of Australia (PCFA) is also undertaking an expert review of the NHMRC-approved clinical guidelines on PSA testing, which were developed in 2016.
It is expected to recommend extending PSA testing to men aged 70, strengthening guidelines for those who have a family history of the disease, and making the tests annual.
"The fact remains that if prostate cancer is detected accurately, before it spreads, it can be effectively managed and treated, eliminating avoidable deaths. Updating the 2016 guidelines is important to help achieve this aim," the PCFA said.
The expert panel will also closely examine changing the starting age for testing.