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PSA Testing for Prostate Cancer in Asymptomatic Men: Information for Health Practitioners submission

ID: 
12
This submission reflects the views of
Organisation Name: 
Andrology Australia
Personal Details
Specific Questions
1. What are the potential benefits of PSA testing?: 

It might be better to re-order the list of potential benefits so that “Reassurance” is the final point. We acknowledge that this may be a benefit but early detection and early treatment are the more important benefits and the main justification for PSA testing.

2. What are the potential harms of PSA testing?: 

Under False negative results: suggest changing “If prostate cancer… false reassurance and delay cancer diagnosis.” to “If prostate cancer… false reassurance and may delay cancer diagnosis.” As some cancers may not ever present clinically, missing one may not delay diagnosis.

3. How frequent are these benefits and harms?: 

Agree with statement.

4. What research has been done to study the effectiveness of PSA testing for prostate cancer?: 

Agree with statement.

5. Does PSA testing in asymptomatic men reduce their risk of dying from prostate cancer?: 

Agree with statement.

6. Does PSA testing in asymptomatic men reduce their overall risk of dying?: 

Agree with statement.

7. Does PSA testing in asymptomatic men reduce their risk of having metastases present at diagnosis of prostate cancer?: 

We felt that the issues covered in the section are too complex to explain in one paragraph and the section could be excluded. As screening tests will always cause a stage shift towards earlier stage disease, this point is implicit in PSA testing; however, the more important issue is whether PSA reduces the risk of later metastases for which the evidence is limited. The surrounding sections on risk of dying from prostate cancer or dying from any cause and quality of life in men diagnosed with prostate cancer cover the important issues for men to consider. 

8. Does PSA testing in asymptomatic men affect the quality of life of men who are diagnosed with prostate cancer?: 

Agree with statement.

9. What is a PSA test?: 

Agree with statement.

10. How accurate is a PSA test?: 

The wording of the statement on false positive tests might be clearer if written as follows: “Approximately 7 out of every 10 men with an abnormal PSA test result will not be diagnosed with prostate cancer after further diagnostic investigation. That is, it is a “false positive” test.”

11. Are there any other screening tests available for prostate cancer?: 

Instead of the sentence “Other tests, such as PCA3…”,including a statement such as “Due to insufficient evidence other tests such as PCA3 and MRI were not considered in this review”  would explain why they were not included.

12. How can men prepare for a PSA test?: 

Either in this section or the next section (What are normal and abnormal PSA test results?): it should be mentioned that 5-alpha reductase inhibitors will affect the PSA level and normal reference range. Many men with benign prostate disease or alopecia will be taking these medications and they need to be taken into account when PSA levels are considered, particularly when PSA levels are seen to be rising.

13. What are normal and abnormal PSA test results?: 

Agree with statement.

14. What happens if a man receives a normal PSA test result?: 

Agree with statement.

15. What happens if a man receives an abnormal PSA test result?: 

Agree with statement.

16. If a man receives a diagnosis of prostate cancer after an abnormal PSA test, what choices does he have?: 

In the sentence listing the choices following diagnosis, add the following: The man may prefer… radiation therapy (external beam or brachytherapy), or androgen deprivation therapy…

In the sentence on watchful waiting and active surveillance, the possibility of further PSA tests and biopsies as part of that process should be included.

17. If a man decides not to have a PSA test what risks should he and his family be aware of?: 

Agree with statement.

General Comments
18. Considering the Information Document is for Health Practitioners, do you have any other comments?: 

In general, the statement is an excellent, succinct contemporary summary and the evidence analysis on which it is based is remarkably well done.We acknowledge thebenefits of using Level 1 evidence as a basis for the statement; however, some argue (and this may have been considered by the committee) that including some lower levelevidence, when no higher level evidence exists, could make the guidelines more comprehensive and increase the likelihood that the statement will be used in clinical practice.

We had concern regarding the use of the term “in asymptomatic men”. This could be misleading as it may perpetuate the misunderstanding that early stage prostate cancer has symptoms. This could either be left out of the title as it is implied that the PSA test is being used in men with no diagnosis of prostate cancer, or there could be a statement in the Introduction stating that early prostate cancer usually has no symptoms. 

After review by our reference group, Andrology Australia endorses the statement for health practitioners.

Page reviewed: 4 March, 2014