Early Testing for Prostate Cancer

written by Dr Thomas Dean MBBS (UNSW), FRCS (Edin) FRACS (Urol)

Patients and doctors alike are confused about the need for early detection of prostate cancer, which results in the death of over 3,000 men in Australia every year. Countless others suffer from the effects of advanced cancer and its treatment, even though they may eventually die from other causes. Before early diagnosis with the PSA blood test became available in the 1980’s, in 80% of the patients the cancer had spread by the time it was diagnosed. Despite our ability to diagnose and treat cancers at an earlier stage with better outcomes, it is surprising that early diagnosis with PSA testing has for many years been highly controversial. The controversy relates to concerns about the risks of prostate biopsies and the risks of the treatments that may be necessary. In addition, some patients may have cancers that do not need to be treated. The situation is complicated further because PSA is not a reliable test. An abnormally raised PSA does not always indicate the presence of cancer and a PSA in the normal range does not exclude significant cancer.

Some doctors advocate early testing so that the cancers can be picked up before they spread and so that treatment is more likely to be successful. Other doctors take the view that a large number of patients do not require treatment, which in those men will cause more harm than benefit. It is a complex issue, but in my opinion it is wrong for doctors to promote their own views. Every patient should be counselled about the benefits and risks and be able to have their cancer diagnosed early if they so desire. Conversely after appropriate counselling they should be able to elect not to have PSA testing.

In recent years there has been a strong focus on identifying those patients who will most benefit from treatment of prostate cancer. In this regard the advent of high quality multi-parametric prostate MRI scans has been very useful. In patients where there is some doubt about the diagnosis, the MRI can help to identify high grade cancers that should be treated and is less likely to detect small low grade cancers that do not require treatment. It is likely that in the future MRI will be used much more to help to determine patient management.