PSA Screening and Prostate Cancer

PSA Screening

Benefits

• Negative test can reassure men who are concerned about prostate cancer.

• Early detection of an aggressive cancer may enable curative treatment (e.g. radical prostatectomy, radiotherapy).

Negatives

• False Negatives: May miss some cancers if PSA is “normal.”

• False Positives: PSA can be elevated by benign causes (BPH, prostatitis) → leads to unnecessary investigations or biopsy.

• Overdiagnosis: Many prostate cancers grow slowly and pose minimal harm; detection might lead to overtreatment.

• Diagnostic Risks: Biopsy complications like bleeding, infection, or urinary issues.

Australian Context

• Routine population-wide PSA screening is not universally recommended.

• No conclusive evidence that PSA screening reduces mortality at the population level. (Applies similarly to ovarian cancer screening, which is also not recommended in asymptomatic women.)

• If men opt for screening (after informed discussion), testing is typically every 2 years up to age 69.

Prostate Cancer

Risk Factors

• Family History: First-degree relative with prostate cancer <65 yrs old → higher risk.

• BRCA1/2 Mutations: Increase risk of early or aggressive disease.

• Age: Risk rises from ~50 yrs onward (earlier in high-risk groups).

• Other: Possibly diets high in saturated fats, but evidence is mixed.

Key Notes

• Shared Decision-Making: Always discuss potential benefits and harms of PSA testing.

• LUTS (from BPH) is not a proven risk factor for prostate cancer.

• Early prostate cancer is commonly asymptomatic.

Causes of Elevated PSA

• Prostatitis or recent UTI

• Benign Prostatic Hyperplasia (BPH)

• Recent Ejaculation or strenuous physical activity involving the perineum (<48 hours)

• Recent DRE (within 1 week)

• Prostate Biopsy (up to 6 weeks post-procedure)

Management of Elevated PSA

Thresholds for Action

• If Total PSA >3 ng/mL (≥50 years), repeat total PSA ± free-to-total ratio in 1–3 months.

• Biopsy if:

  • Total PSA >5.5 ng/mL OR

  • Total PSA 3–5.5 ng/mL + free-to-total ratio <25%

• For men <50 years, use age-specific PSA percentiles:

  • <75th percentile: Reassess at age 50

  • 75–95th percentile: Test every 2 years (3× increased risk)

  • 95th percentile: Further investigation

  • (Free-to-total ratio less reliable in younger men)

Special Considerations

• Prostatitis/UTI: Defer PSA testing until infection/inflammation has resolved (usually ~6 weeks).

• Biopsy: Consider only after thorough discussion of benefits vs. risks (bleeding, infection, anxiety).

• Age >70: Rarely recommended unless strong family history or high-risk factors.

Testing Recommendations

• Test only in well-informed men after shared decision-making, focusing on men >45 years with risk factors (family history, known genetic predisposition).

• Avoid frequent testing if normal for age.

• If deciding to screen, typically every 2 years until age 69 (or older if clinically indicated and in robust health).