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

ID: 
15
This submission reflects the views of
Organisation Name: 
NSW Ministry of Health
Personal Details
Specific Questions
2. What are the potential harms of PSA testing?: 

It may be helpful to help men understand the likelihood that a test will be false-positive or false-negative. (And how many will have a “positive” test – a “positive” test is not a rare event according to the evidence evaluation report).

3. How frequent are these benefits and harms?: 

For every 1000 men tested, 2 men will avoid death from prostate cancer before 85 years of age because of PSA testing*.

Appears inconsistent with the evidence evaluation report statement:

The present evidence is inconsistent as to whether there is an effect of PSA testing, with or without DRE, on the risk of prostate cancer-specific mortality compared with no PSA testing, although the possibilities of no effect or a small protective effect cannot be excluded;

It should also be put in context that:

PSA testing with or without DRE has no discernible effect on all-cause mortality compared with no PSA testing;

In other words that it is unlikely to prolong your life.

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

Appears consistent with the evidence evaluation report

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

Appears consistent with the evidence evaluation report

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

Appears consistent with the evaluation report

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

Appears consistent with the evaluation report

9. What is a PSA test?: 

There is no comment here that PSA testing is not routinely recommended to men who have no symptoms of average risk. There should be a comment to this effect.

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

It indicates the possible presence of prostate cancer, but it does not confirm that cancer is present.

Comment: in 70% of men, an abnormal result does not indicate cancer is present.

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

There should be a comment in this section that prostate cancer screening is not routinely recommended because of the uncertainties around benefits and harms.

Not being screened is an appropriate decision for many men.

Suggest the wording is “possible potential” benefits of testing.

The man should be reassured that based on the current evidence there is likely to be no life-saving benefit  from having the test (given the lack of evidence of influence on all-cause mortality).

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

The Evidence Evaluation report notes that “PSA testing is suspected to be largely opportunistic and is often used in conjunction with a DRE.”

 The PSA testing for Prostate Cancer in Asymptomatic Men: Information for Health Practitioners document does not help a primary care provider know whether this is good ethical practice or not.

 Key information Health Practitioners might wish to know:

1) Is having a conversation about PSA testing as part of a routine physical examination an expected standard of care in an asymptomatic individual?      (Suggested answer from the evidence evaluation report: Given the potential harms and benefits it is unlikely that this should be an expected standard of care)

2) Should the PSA test be offered routinely in the context of informed consent as part of a routine physical examination in asymptomatic individuals over a certain age?

(Suggested answer from the evidence evaluation report: Given the potential harms and benefits it is unlikely that this should be an expected standard of care)

These two questions are posed as it appears from the testing profile of Australian men many health care practitioners believe that it *is* an expected standard of care. They need reassurance that PSA testing should not be routine for asymptomatic men. This document helps guide a health care practitioner with a patient in front of them requesting a PSA test make a more informed decision. It doesn’t help them decide whether to offer a conversation about the test or to offer the test .

A statement similar to the RACGP’s Red Book may help clarify this issue:

GPs need not raise this issue, but if men ask about prostate screening they need to be fully informed of the potential benefits, risks and uncertainties of prostate cancer testing

3) At what age is it is unreasonable to order a PSA test in an asymptomatic person

(eg if an asymptomatic person <40 of average risk presents for a men’s health check what should the advice be?)

Page reviewed: 4 March, 2014