One of the joys of a 50th birthday is receiving invitations for cancer screening. Women are invited to join the national breast cancer screening program, and both genders receive a letter inviting them to submit a specimen for bowel cancer screening. These are critical preventive national health programs that play an important role in protecting older Australians.
Have you wondered why no Australian man receives an invitation to participate in a screening program for prostate cancer? Prostate cancer is the most common malignant disease in men. Close to 25,000 Australian men find out they have prostate cancer, and more than 3500 die from the condition every year.
For comparison, there are about 21,000 new cases of breast cancer and 3200 women die of the disease yearly.
Just over 8000 men are diagnosed with bowel cancer each year and the condition takes the lives of about 2800 men.
Finding unsuspected breast and bowel cancers at an early stage saves lives. If found before they have spread, the chances of long-term survival are close to 99 per cent. Even with a small amount of spread, the chances of survival for both cancers can be almost 90 per cent.
The screening test for prostate cancer is a blood test that measures prostate-specific antigen, or PSA. The test is logistically simpler than those either for bowel or breast cancer.
As things stand, it’s recommended that men “discuss the benefits and harms of PSA testing” before making any decision to be tested.
Men who decide to have screening are offered a second-yearly PSA check from age 50, stopping at age 69. Men with a family history of the disease may begin testing earlier. Because there is no national screening program, men must pay the cost of the consultation with their GP and the cost of the PSA test itself.
Prostate cancer only causes its signature symptoms – problems passing urine, pain, and issues with sexual function – in its very late stages. By then the outlook for long-term survival is grim: only half of men with late-stage prostate cancer will survive beyond five years.
If prostate cancer is found early, before any symptoms, the outlook is good. The vast majority will live long lives and, indeed, are more likely to die of some other cause than a consequence of their prostate condition.
Unlike breast and bowel cancer, there is no national screening program for prostate cancer. Men who don’t bring it up with their doctors, or who don’t go to see a doctor, might not even be aware that tests are available. This situation has been under review since 2022, with no resolution yet in sight.
Why is such a common cancer, one that takes thousands of lives each year, still on the back burner? Medicare data suggest that only about one in five Australian men aged 45–74 choose to have a PSA test each year. The majority of Australian men either don’t know about screening or choose not to have it after discussing it with their doctors.
As things stand, screening for prostate cancer is hit-and-miss, essentially requiring men to raise it with their doctors and invite a discussion of pros and cons. This approach arises not from concerns about improving men’s chances of surviving, but about the potential implications of “over-diagnosing” the condition.
Over-diagnosis is the situation where potentially harmful treatment is offered for cancers that are relatively slow-growing and unlikely to kill. Traditional methods of taking a biopsy from the prostate can cause serious infections. Surgery to remove the prostate can have devastating effects on a man’s ability to have an erection and may leave men incontinent.
PSA, while specific to the prostate gland, is not specific to cancer. Everything from ejaculation to bicycle riding (a common combination for urban men these days) and benign enlargement of the prostate can raise PSA levels. A single high reading requires repeat testing but is not enough for a diagnosis of cancer.
None of these terrible outcomes is worthwhile if they are sustained during treatment of a “harmless” cancer that came to light with PSA testing.
The current prostate cancer screening guidelines were developed close to a decade ago and rely on scientific and medical evidence from patients treated literally many decades ago. This is important to understand, because the ways that an abnormal PSA result can be investigated – and cancer found and treated – have undergone radical changes since the current guidelines came into force.
An Australian study, published last year in the International Journal of Cancer, showed that for 1000 men who undergo the screening program (a PSA blood test every two years from age 50 to 69), 36 men would go on to die from prostate cancer. For 1000 men who don’t have the testing, 50 will die from it. The issue is that for every man who is diagnosed with prostate cancer, two will be over-diagnosed and potentially subjected to harmful and unnecessary invasive tests and treatments.
Advances in the way a diagnosis of prostate cancer is confirmed, and confirmed cancer is treated, have almost been revolutionised. Even more nuanced analysis of a PSA result can reduce the risk of harmful overdiagnosis.
Use of “biomarker” and genetic “precision medicine” techniques can help identify more aggressive cancers, and guide treatment decisions.
In some cases, biopsy can be avoided by using sophisticated MRI scans. When a biopsy is needed, new techniques may be suitable that carry lower rates of infection. Options other than radical prostate surgery are available for many men – including radiation, hormone, and chemotherapy treatments. Not every man will have to undergo major surgical procedures; some will simply need close ongoing monitoring.
It seems unlikely that a national prostate cancer screening program will come into being. However, it might be time to make sure that all men of a certain age know that screening is available. Receiving one of those 50th birthday letters suggesting a discussion with a doctor might be a worthwhile initiative. Letters are sent to men anyway so it should be cost-neutral to run while we wait for the next iteration of the national screening guidelines.
Professor Steve Robson is one of Australia’s most highly qualified surgical specialists, researchers and teachers. He works at the Australian National University Medical School.
This column is published for information purposes only. It is not intended to be used as medical advice and should not be relied on as a substitute for independent professional advice about your personal health or a medical condition from your doctor or other qualified health professional.
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