When to see a doctor?
Make an appointment with your doctor if you have any signs or symptoms that worry you.
Debate continues regarding the risks and benefits of prostate cancer screening, and medical organizations differ on their recommendations.
Discuss prostate cancer screening with your doctor. Together, you can decide what's best for you.
The Prostate Cancer Foundation of Australia (PCFA) in partnership with Cancer Council Australia and a multi-disciplinary expert advisory panel comprising urologists, radiation oncologists, pathologists, general practitioners, medical oncologists, epidemiologists, allied health professionals and consumers, has developed national evidence-based clinical practice guidelines on PSA testing and early management of test-detected prostate cancer.
The guideline recommendations have been approved by the CEO of the National Health and Medical Research Council, Australia's leading expert body for developing health advice for the Australian community, health professionals and governments.
Prostate Specific Antigen (PSA) Test
Prostate specific antigen (PSA) is a protein made in the prostate. It is mostly secreted into the semen to make it thinner, or more watery, to help the movement of sperm, but a small amount is also released into the bloodstream. A PSA test measures the amount of prostate specific antigen in the blood.
PSA levels in the blood may be higher than normal if you have certain conditions, such as prostate infection or inflammation (prostatitis), prostate enlargement or prostate cancer.
Why is a PSA test done?
The PSA test can be used to help in the diagnosis of prostate cancer. It can also be used as a method of screening for prostate cancer in healthy men, although there is ongoing debate about its use as a screening test (see below).
PSA tests are also used to monitor prostate cancer and its treatment.
Who should have a PSA test?
Using PSA tests as screening tests to help detect prostate cancer early in men without symptoms is controversial. Guidelines developed in 2015 by the Prostate Cancer Foundation of Australia and the Cancer Council Australia recommend the following:
- Men should discuss the risks and benefits of PSA testing with their doctor before deciding whether they should have this test.
- Men at average risk of prostate cancer who decide to have PSA screening tests should be offered PSA testing every 2 years from age 50 to 69.
- Men with a family history of prostate cancer who decide to have PSA screening tests should be offered testing from a younger age (40-45 years), depending on how many close family members have been diagnosed with prostate cancer.
- For men older than 70, the harms of PSA screening tests may outweigh the benefits.
Australian health professional bodies agree that there is not enough evidence to recommend routine PSA tests in all men to screen for prostate cancer.
What are the benefits of PSA tests?
PSA screening tests are aimed at detecting aggressive prostate cancers at an early stage - before they have caused any symptoms and when they are still curable.
If you have already been diagnosed with prostate cancer, regular PSA testing may be done to monitor the cancer. This may be as part of an ‘active surveillance’ approach — if the cancer is thought unlikely to spread or cause problems, doctors may monitor it using PSA tests and other investigations rather than treating it straight away. Alternatively, if you have had treatment for prostate cancer, PSA tests may be done to assess the effects of that treatment.
Limitations and risks of PSA tests
One limitation of PSA tests is that a high PSA level can be caused by several conditions - PSA is not specific for prostate cancer. In fact, most men with a high PSA result are found not to have prostate cancer.
Another limitation is that PSA tests cannot differentiate between slow-growing and aggressive prostate cancers. About 20-40 per cent of prostate cancers that are detected through PSA screening are found to be the slow-growing, low-risk type that would most likely never have caused harm if left untreated.
The harms of potentially unnecessary tests and treatments in these cases may outweigh the benefits. In addition, an abnormal PSA test result and the need to decide on further tests can cause significant anxiety.
False negative PSA results are also possible. This is when men who do actually have prostate cancer have a normal PSA test result.
Limitations and risks of PSA tests
One limitation of PSA tests is that a high PSA level can be caused by several conditions - PSA is not specific for prostate cancer. In fact, most men with a high PSA result are found not to have prostate cancer.
Another limitation is that PSA tests cannot differentiate between slow-growing and aggressive prostate cancers. About 20-40 per cent of prostate cancers that are detected through PSA screening are found to be the slow-growing, low-risk type that would most likely never have caused harm if left untreated.
The harms of potentially unnecessary tests and treatments in these cases may outweigh the benefits. In addition, an abnormal PSA test result and the need to decide on further tests can cause significant anxiety.
False negative PSA results are also possible. This is when men who do actually have prostate cancer have a normal PSA test result.
Risks associated with further testing and treatment
New If your PSA result is abnormal, you will usually be offered a biopsy test to determine whether it is caused by prostate cancer, and if so how aggressive it is. A prostate biopsy involves taking small pieces of tissue from the prostate for examination under a microscope. Risks associated with prostate biopsy include discomfort, pain and infection.
Treatments for prostate cancer are associated with side effects such as urinary incontinence, bowel problems and erectile dysfunction.
Should you have a PSA test?
If you are thinking of having a PSA test for screening purposes, you should see your GP to talk over the risks and benefits of the test — and those of further investigations or treatment if the PSA test is abnormal.
When advising you, your doctor will take into account:
- your age;
- any symptoms you have; and
- factors that can increase your risk of prostate cancer, such as a family history of prostate cancer and having had a previous abnormal PSA test or prostate biopsy.
Having the PSA test may be more worthwhile if you have risk factors for prostate cancer than if you don’t — but whether to have the test is still an individual decision. To some extent, it depends on how you feel about cancer, investigations, treatment and your overall health. Your doctor can help you clarify what’s important to you.
How is a PSA test done?
The PSA test is a simple blood test. It’s done by taking blood from a vein — usually in your arm — and sending it to the lab for analysis.
Before you have a PSA test, tell your doctor about any medicines, supplements or herbal products you are taking, as they may affect the results. One medicine in particular, finasteride (e.g. Propecia, Proscar), which is used for treating male pattern baldness and benign prostatic hypertrophy (non-cancerous prostate enlargement), can affect PSA results.
You should also tell your doctor if you have had any urinary problems or investigations of the urinary tract such as a prostate biopsy or cystoscopy in the few weeks before a PSA test is scheduled, as these can also affect the results.
As ejaculation can make PSA levels rise briefly, some doctors recommend avoiding sexual activity for 24-48 hours before a PSA test.
What if your PSA test result is abnormal?
Your doctor will interpret your PSA results on the basis of your age — PSA levels tend to increase naturally as men get older. There is no specific cut-off point between a normal and abnormal PSA result, but as a general guide, if your total PSA concentration is higher than 3 ng/mL, your doctor may offer you further tests.
Your doctor may initially recommend that the PSA test be repeated in several weeks and may request more detailed blood PSA testing (including whether PSA is ‘free’ or attached to other blood proteins - ‘bound PSA’).
Your doctor or urologist (a specialist in the urinary system and men’s reproductive organs) may perform a digital rectal examination (DRE) — an examination in which the doctor inserts a gloved finger into the rectum to feel for abnormalities in the prostate.
Your doctor or specialist may also suggest further tests, such as a biopsy of the prostate or special MRI scans. Treatment and/or follow up will depend on your test results.
Remember, there are many potential reasons for a raised PSA level, including infection, inflammation and non-cancerous enlargement of the prostate, as well as prostate cancer.
Whether or not to have a PSA screening test is up to you - discuss the pros and cons, as well as your individual risk, with your doctor so that you can make an informed decision.
What does the test result mean?
The 'normal' value for total PSA are age dependent but total PSA levels greater than 10.0 µg/L may indicate a high probability of prostate cancer. Levels between 4.0 µg/L and 10.0 µg/L may indicate BPH, a non-cancerous swelling of the prostate, or prostate cancer. BPH occurs most frequently in elderly men. Increased total PSA levels may also indicate a condition called prostatitis, which is caused by an infection. It is important to realise that an elevated PSA level does not always indicate the presence of prostate cancer.
There is some evidence that the free PSA ratio (the percent of total PSA not bound to proteins) can help predict the probability of cancer, especially in patients with total PSA levels in the 'grey-area' range of 4.0 to 10.0 µg/L. This test may also be useful in early diagnosis of disease when values are between 2.5 and 4.0 µg/L. A free-PSA test result above 25% is thought to suggest a lower risk of cancer, whereas a lower percentage suggests a higher probability of disease. This ratio may help reduce the number of unnecessary biopsies. A recent study also suggests that very low ratios of free PSA to total PSA (less than 14%) might be associated with a more aggressive form of the disease. Additional studies are ongoing.
In most cases, test results are reported as numbers rather than as 'high' or 'low', 'positive' or 'negative', or 'normal'. In order for the doctor to properly understand laboratory results it is necessary for them to know what the reference range is for a particular test. However, reference ranges can be influenced by the patient's age and sex and, amongst other things, by what drugs they are receiving, the time of day and what they have eaten. Reference ranges can also be influenced by the test method and instrument used by laboratory.
Digital Rectal Exam(DRE)
The digital rectal exam (or DRE) is an essential part of the early detection and diagnosis of prostate cancer. It is also, however, a source of anxiety for many men.
Why Is the digital rectal examperformed?
The digital rectal exam is performed to detect abnormalities in the lower pelvis. A number of important anatomic structures are located in the lower pelvis including the prostate and the rectum/lower colon.
By examining these structures, abnormalities can be detected that may otherwise have been missed with blood tests (such as the PSA test) or imaging tests (such as CT or MRI exams).
How is the digital rectal exam performed?
To begin, you will be asked to remove any clothing below the waist. You may also be given a hospital gown to wear.
You will then be asked either to bend over at the waist with your hands on the examining table or to lay on your left side with your knees drawn up toward your chest. Both of these positions allow for better examination and improved comfort during the test.
Next, your doctor will put a gloved, lubricated finger into your rectum and examine the prostate. To do this properly, firm pressure will need to be applied to the prostate. When the prostate has been thoroughly examined, the test is complete. The entire exam usually takes only a few seconds.
What do you need to do prior to a digital rectal exam?
There is nothing that you need to do prior to a digital rectal exam. You can eat, exercise and otherwise do what you normally do prior to this exam.
Potential risks or side effects
Nearly all men state that a digital rectal exam is somewhat uncomfortable, but not painful. If the prostate is inflamed due to a condition such as prostatitis, the exam can be somewhat painful, however.
Because firm pressure needs to be applied to the prostate during the exam, this can cause you to feel that you need to urinate immediately. This sensation typically passes once the exam is completed.
You may have a very small amount of bleeding after the exam is done. This is more likely if you have haemorrhoids or other rectal problems. Most men have no bleeding.
It is also possible that the uncomfortable nature of the exam could cause you to have a vasovagal response. If this occurs, you may feel very lightheaded or possibly even faint. This, again, is rare and most men have no such issue.
MRI of the prostate
Magnetic Resonance Imaging (MRI) is a safe, painless and powerful diagnostic imaging test. MRI technology is very complex but essentially uses a strong magnetic field and radio waves to produce exquisite images of the prostate. MRI does not use radiation. Prostate MRI scans are typically completed within 40 minutes.
What is the evidence for prostate MRI?
The likelihood of having prostate cancer can be determined by digital rectal examination and a blood test which measures PSA, a protein secreted by normal prostate cells and in larger amounts by prostate cancer. The problem is that an elevated PSA does not definitely indicate prostate cancer as it can also be raised in non-cancerous conditions such as aging related enlargement, inflammation and infection. In fact certain activities like having sex or riding a bike can trigger a temporary increase in PSA that has nothing to do with prostate cancer and conversely a normal PSA does not exclude prostate cancer.
Systematic biopsies of the prostate until now have been the gold standard for evaluating raised PSA and prostate cancer diagnosis. Whilst they have been shown to save lives, biopsies have also been shown to detect relatively harmless, insignificant cancers which pose no real threat to a man’s life expectancy. Furthermore a biopsy sometimes will miss an aggressive cancer particularly if it is located in the front part of the prostate gland beyond the reach of the biopsy needle.
Prostate Multi-Parametric MRI is a non-invasive imaging test that has emerged recently as the best examination available for detecting significant (‘harmful’) prostate cancer earlier. It is also advantageous that MRI does not pick up harmless cancers which would lead to unnecessary overtreatment.
It also enables accurate evaluation of spread outside the prostate gland which is important when it comes to treatment options. Understanding the extent of disease enables the surgeon to determine whether it is possible to preserve the delicate arteries and nerves which are essential for maintaining sexual function and bladder control.
Pre Biopsy MRI
If your PSA is elevated many world experts consider it to be advantageous to have an MRI prior to a biopsy for the investigation of prostate cancer. In some patients MRI can be so convincingly negative that we can say more reliably than with biopsy that there is no significant cancer in the prostate. This means your doctor may decide not to proceed to a biopsy. The MRI will in essence give you peace of mind. If you and your doctor still decide to proceed to a biopsy your MRI will add considerably to the certainty that a significant cancer is not missed by the biopsy.
If cancer is detected on MRI, the MRI will give better information with regards to its location, size, grade and extent, important information that your Urologist needs when it comes to diagnosis and treatment planning.
Post Biopsy MRI
If you have already had a biopsy, which did not show cancer and your PSA is still raised or rising, a subsequent MRI can further evaluate for missed prostate cancer as a possible cause for your elevated PSA.
There is also evidence that MRI has added an extra dimension to the monitoring of men undergoing active surveillance or follow up after radical treatment, resulting in many fewer biopsies.
Does the Medicare Benefits Scheme (MBS) cover the cost of MRIs?
From 1 July 2018, Medicare rebates will be available for four items covering mpMRI prostate scans for both the diagnosis of prostate cancer (items 63541 K & 63542 NK) and the active surveillance of patients with a proven diagnosis following biopsy histopathology (items 63543 K & 63544 NK). The MBS fee for K items 63541 and 63543 will be $450. For the NK equivalents, 63542 and 63544, the MBS fee will be $225. All items include the use of contrast.
Who can request these items?
Urologists, radiation oncologists and medical oncologists are eligible to request these items. General practitioners are not eligible to request these items.
What are the patient eligibility requirements?
These items are only for scans of patients with specified indications. The request form must list the relevant clinical indications.
For MBS items 63541 and 63542 (NK) the patient must be suspected of having prostate cancer based on:
- a) a digital rectal examination (DRE) which is suspicious for prostate cancer; or
- b) in a person aged less than 70 years, at least two prostate specific antigen (PSA) tests performed within an interval of 1- 3 months are greater than 3.0 ng/ml, and the free/total PSA ratio is less than 25% or the repeat PSA exceeds 5.5 ng/ml; or
- c) in a person aged less than 70 years, whose risk of developing prostate cancer based on family history is at least double the average risk , at least two PSA tests performed within an interval of 1- 3 months are greater than 2.0 ng/ml, and the free/total PSA ratio is less than 25%; or
- d) in a person aged 70 years or older, at least two PSA tests performed within an interval of 1- 3 months are greater than 5.5ng/ml and the free/total PSA ratio is less than 25%.
Note: Relevant family history is a first degree relative with prostate cancer or suspected of carrying a BRCA 1, BRCA 2 mutation.
For MBS items 63543 and 63544 (NK) the below clinical criteria must be met:
- a) the patient is under active surveillance following a confirmed diagnosis of prostate cancer by biopsy histopathology; and
- b) the patient is not planning or undergoing treatment for prostate cancer.
Are there any restrictions on the number of services?
Medicare benefits for MBS items 63541 and 63542 (NK) are only payable once per patient in a twelve month period.
Benefits for MBS items 63543 and 63544 (NK) are payable for patients with proven diagnosis of prostate cancer following biopsy histopathology who:
have not had a diagnostic mpMRI, and are placed on active surveillance following confirmed diagnosis; or
12 months following confirmed diagnosis and then every third year thereafter; or
at any time there is a clinical concern, or concern with PSA progression.
Note: MBS items 63543 and 63544(NK) are not to be used for the purpose of treatment, planning or for monitoring after treatment.
Where can the procedure take place to be eligible for a Medicare rebate?
A Medicare benefit will only be payable for an mpMRI prostate scan if the service is performed on an eligible MRI unit with either full or partial Medicare eligibility.
Prostate Biopsy
Prostate biopsy is usually recommended when the results of initial tests, such as prostate-specific antigen (PSA) blood test or digital rectal exam (DRE), raise concerns of possible cancer.
Occasionally the biopsy does not detect prostate cancer but does detect some abnormal cells which may indicate that there may in fact be prostate cancer somewhere within the prostate. Under these circumstances, a repeat biopsy may be indicated.
What is involved in a prostate biopsy?
A prostate biopsy involves taking tiny samples of tissue from the prostate to check if there is cancer. If there is cancer, you will be able to know “Gleason Grade” which gives a score as to how aggressive the cancer may be.
The biopsy procedure is performed by an urologist. Depending on the type of biopsy, you will have either local or general anaesthetic.
An ultrasound probe is placed into rectum and the entire prostate is scanned. Then either of transrectal or a transperineal biopsy (+/- MRI fusion) is performed.
Types of prostate biopsy:
- Transrectal biopsy:
- Transperineal biopsy:
- Transperineal biopsy with MRI fusion:
Each of these techniques have their respective benefits and downsides and your specialist will discuss which is best suited for you.
The key differences between the 2 techniques:
- The transrectal biopsy is quicker and does not need a general anaesthetic. It is possible to be done in the clinic and so you do not need to go into the hospital. However it is associated with a higher rate in infections as the probe passes through rectum. However, this rate of infection is still low at ~3%.
- The transperineal biopsy is associated with less infection and allows easier sampling in the anterior part of the gland. In addition, many more cores are usually taken compared to the transrectal biopsy which means that the results are more accurate. However, it involves a general anaesthetic, takes longer and may be associated with more short-term urinary flow problems.
Understanding the results
The Gleason grading system is used to help evaluate the prognosis of men with prostate cancer using samples from the prostate biopsy. Together with other parameters, it is incorporated into a strategy of prostate cancer staging which predicts prognosis and helps guide therapy. A Gleason score is given to prostate cancer based upon its microscopic appearance. Cancers with a higher Gleason score are more aggressive and have a worse prognosis. Pathological scores range from 2 through 10, with higher number indicating greater risks and higher mortality.
A total score is calculated based on how cells look under a microscope, with the first half of the score based on the dominant, or most common cell morphology (scored 1—5), and the second half based on the non-dominant cell pattern with the highest grade (scored 1—5). These two numbers are then combined to produce a total score for the cancer.
When a doctor tells you what the Gleason score is, it will be between 2 and 10. Although it is not always the case, the higher the score, the more aggressive the cancer tends to be. Typically, lower scores indicate less aggressive cancers.
In most cases, scores range between 6 and 10. Biopsy samples that score 1 or 2 are not used very often because they are not usually the predominant areas of cancer.
A Gleason score of 6 is usually the lowest score possible. Prostate cancer with a score of 6 is described as well-differentiated or low-grade. This means the cancer is more likely to grow and spread slowly.
Scores between 8 and 10 are referred to as poorly differentiated or high-grade. In these cases, the cancer is likely to spread and grow quickly. Scores of 9 and 10 are twice as likely to grow and spread quickly as a score of 8.
In the case of a score of 7, the results could be one of two ways:
3 + 4 = 7
4 + 3 = 7
This distinction indicates how aggressive the tumour is. Scores of 3 + 4 typically have a good outlook. A score of 4 + 3 is more likely to grow and spread compared to the 3 + 4 score, but it is less likely to grow and spread than a score of 8.
In some cases, a person may receive multiple Gleason scores. This is because the grade may vary between samples within the same tumour or between two or more tumours. In these cases, the doctor is likely to use the highest score as the guide for treatment.
The Gleason scale is very important for doctors when they decide the best treatment options, but is not the only factor they take into consideration.
