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Public Health Res Pract. 2017 Jul 26;27(3). pii: 2731721. doi: 10.17061/phrp2731721.

PSA testing for men at average risk of prostate cancer.

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School of Population Health, University of Western Australia, Perth; Sydney School of Public Health, University of Sydney, NSW, Australia.
General Medicine Division, Massachusetts General Hospital, Boston, US; Department of Medicine, Harvard Medical School, Boston, MA, US.
Urological Society of Australia and New Zealand, Sydney, NSW, Australia; Department of Surgery, Faculty of Medicine, Monash University, Melbourne, Vic, Australia.
Faculty of Medicine, University of Queensland, Brisbane, Australia; Centre for Clinical Research, University of Queensland, Brisbane, Australia; Royal Brisbane and Women's Hospital, Qld, Australia; School of Medical and Health Sciences, Edith Cowan University, Perth, WA, Australia; Griffith University, Brisbane, Qld, Australia.
Cabrini Haematology and Oncology Centre, Cabrini Hospital, Melbourne, Vic, Australia; AMREP Department of Medicine, Faculty of Medicine, Monash University, Melbourne, Vic, Australia.
Centre for Values, Ethics and the Law in Medicine, University of Sydney, NSW, Australia,


Prostate-specific antigen (PSA) testing of men at normal risk of prostate cancer is one of the most contested issues in cancer screening. There is no formal screening program, but testing is common - arguably a practice that ran ahead of the evidence. Public and professional communication about PSA screening has been highly varied and potentially confusing for practitioners and patients alike. There has been much research and policy activity relating to PSA testing in recent years. Landmark randomised controlled trials have been reported; authorities - including the 2013 Prostate Cancer World Congress, the Prostate Cancer Foundation of Australia, Cancer Council Australia, and the National Health and Medical Research Council - have made or endorsed public statements and/or issued clinical practice guidelines; and the US Preventive Services Task Force is revising its recommendations. But disagreement continues. The contention is partly over what the new evidence means. It is also a result of different valuing and prioritisation of outcomes that are hard to compare: prostate cancer deaths prevented (a small and disputed number); prevention of metastatic disease (somewhat more common); and side-effects of treatment such as incontinence, impotence and bowel trouble (more common again). A sizeable proportion of men diagnosed through PSA testing (somewhere between 20% and 50%) would never have had prostate cancer symptoms sufficient to prompt investigation; many of these men are older, with competing comorbidities. It is a complex picture. Below are four viewpoints from expert participants in the evolving debate, commissioned for this cancer screening themed issue of Public Health Research & Practice. We asked the authors to respond to the challenge of PSA testing of asymptomatic, normal-risk men. They raise important considerations: uncertainty, harms, the trustworthiness and interpretation of the evidence, cost (e.g. of using multiparametric magnetic resonance imaging to triage patients with elevated PSA), a likely bias towards intervention (particularly for cancer), and the potential to limit harm by treating more conservatively (although this may not occur consistently). They provide important insights, and disagree on some issues, but generally concur that men should decide for themselves whether to be tested. It seems reasonable to support men's autonomy to make their own decisions based on their own values. However, the support men might require to decide is likely to be considerable, and this needs to be taken seriously in policy making.

[Indexed for MEDLINE]
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Conflict of interest statement

BA’s then-employer, the Sax Institute, was reimbursed by the PCFA for remunerated time spent advising the systematic evidence review team for the PSA testing guideline and on writing parts of the guideline document. BA chairs the PCFA’s Research Advisory Committee and is an ex officio member of its National Board. BA receives no remuneration for either of these memberships, but all expenses for attending meetings are paid for by the PCFA, and he attends Committee and Board dinners hosted by the PCFA. BA is an Associate Investigator of a PCFA-funded randomised controlled trial of vitamin D in the prevention of progression of prostate cancer managed by active surveillance. He was one of the initiators of the process to develop an Australian guideline for PSA testing and the early management of test-detected prostate cancer, and was a member of the expert advisory panel that oversaw development of the guideline and agreed on its final text. MB is a member of the USPSTF. His viewpoint does not necessarily represent the views and policies of the USPSTF. MB received salary support from the nonprofit organisation Healthwise as Chief Science Officer, and Healthwise provided grants to Massachusetts General Hospital for MB’s prostate-related and shared decision making research. RG is a member of the Andrology Australia Advisory Board and is also involved in NHMRC- and Movember-supported research into management of men with prostate cancer. RG and MF were members of the expert advisory panel for the NHMRC-approved Australian guidelines for PSA testing. IH is a consultant oncologist who sees men in paid consultations who want second opinions about how to proceed with their PSA or biopsy results.

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