But not everyone agrees with the recommendations, which would significantly change how GPs screen and treat patients.
The draft 2025 clinical guidelines for the early detection of prostate cancer have been released and some changes have sparked a strong response from the RACGP.
The Prostate Cancer Foundation of Australia (PCFA) is replacing the current 2016 version and changing who is screened and when, who is offered active surveillance or definitive treatment, and removing biopsy as the primary test following an elevated PSA, among other things.
“We need these new guidelines, because much has changed over the last decade in the diagnosis of prostate cancer,” said Dr Brett Montgomery, RACGP representative on the guidelines steering committee.
He said many GPs found it challenging to counsel patients about early detection of prostate cancer, but the update will provide clear guidance about PSA testing and interpreting results, including flowcharts of action points that are easy to read and implement.
The guideline includes new risk factors, with particular focus on recognising Aboriginal and Torres Strait Islander males as a priority population due to worse survival outcomes than the general Australian population.
There were no specific recommendations for this population in the previous guideline, but now PSA testing is recommended every two years from the age of 40. The PCFA highlighted this as a world-first recommendation.
Dr Montgomery told Oncology Republic that the recommendation to offer testing to males aged 50-69 is still what is best supported by evidence. However, the update offers support for starting screening earlier for people at increased risk.
“They offer some cautious flexibility in the age of starting and stopping testing: allowing doctors to respect patient choice in testing from age 40 or beyond age 70 in people who are keen and relatively well, even though evidence of benefit in these age groups is much more slender,” he said.
However, the RACGP expressed “major concerns” with the move, saying the disparity in mortality rates for Aboriginal and Torres Strait Islander people was likely due to access to and engagement with health systems.
“The evidence cited in the draft guideline shows no significant difference in the age of diagnosis or spread of disease at diagnosis in Aboriginal and Torres Strait Islander men,” said Professor Mark Morgan, chair of the RACGP expert committee.
“Therefore, while they are a priority population, the RACGP is concerned this approach may lead to more unintentional harms, such as false positive PSA tests and overdiagnosis.”
For Aboriginal and Torres Strait Islander men aged 40-49, a PSA of 1.0μg/L or greater, or a PSA of 2.0μg/L or greater for men aged 50-69, would prompt a repeat test within three months. These age and PSA ranges also apply to other risk factors that were not identified in the 2016 guideline, such as black males of sub-Saharan ancestry, males with a BRCA2 gene mutation and a family history of prostate cancer.
Family history specifically refers toas a brother diagnosed with prostate cancer, a father diagnosed with prostate cancer before the age of 65 and/or two or more second degree relatives who died of prostate cancer. The draft suggests that these risk factors can more than double the risk of an individual dying from prostate cancer.
The RACGP recommended including men who take exogenous anabolic steroids as a risk factor, not because they’re at a higher risk of prostate cancer but because these medications may stimulate prostate cancer growth.
There are also proposed changes to who should be offered active surveillance.
The PCFA recommends reducing the PSA threshold from 20μg/L to 10μg/L and requiring a PSAD of 0.15μg/L/mL or less, an MRI PI-RADS of 3 or less and a clinical stage of T1-T2a. All criteria must be met to offer active surveillance.
The previous guideline did not advise testing men over the age of 70, but the new guideline aims to reverse that, recommending testing based on clinical assessment rather than age alone.
The RACGP asked for clarification, suggesting that clinical assessment should be clearly defined and include life expectancy, comorbidities, and patient values and preferences.
It also recommended adding guidance for GPs on making a shared decision to discontinue testing in healthy men aged 70 and over with a PSA less than 1.5μg/L, as these individuals were unlikely to benefit from further screening.
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“A problem in the past has been that only a tiny proportion of participants have their life saved through early detection. And these benefits have needed to be weighed against the hazards of prostate screening, including overdiagnosis,” said Dr Montgomery.
He said that for every 1000 people getting tested, they see around one life being saved after 11 years, two after 16 years, and perhaps four after 25 years and 14 after 40 years. These numbers were outlined in the RACGP submission, which cautioned potential overdiagnosis from the expansion of screening recommendations.
The previous guideline had a lot of criteria for offering definitive treatment, but the update suggests that it only requires either pathological progression detected from a biopsy or based on patient preference.
Under the new guidelines, biopsy will no longer be considered the primary testing approach after an elevated PSA. mpMRI is now the preferred first diagnostic test following a raised PSA result and will determine if a biopsy is required.
Ultrasound-guided transperineal approach is now the preferred biopsy method to reduce infection risk, as opposed to transrectal. The optimal number of cores for targeted biopsy have been reduced from 21-24 to a minimum of 3-4.
The RACGP recommended the development of a national registry for prostate cancer screening be considered by the PCFA.
“This will help avoid duplication of testing for patients who see multiple providers, as a central system will capture people who move to a different GP and/or clinic, and allow GPs to undertake the recalls and reminders for screening,” they wrote.
They also suggested providing a clear list of changes to screening tests, such as the removal of the free-to-total ratio.
“I would like to see the development of resources that help GPs to work with their patients to weigh the good things and the bad things about testing so that patients can reach a decision on testing that is in keeping with their own values,” Dr Montgomery said.
“I know that good people are working on such a resource now.”
This article was updated to include comments by Dr Montgomery.
