The great PSA debate #pcwc13

This week in Melbourne the prostate cancer world conference was held.

The consensus statement this produced/publicised is linked below.

I think we can all agree the PSA cat is out of the bag and has had kittens. There is no going back to Pre-PSA testing but the harms of testing/treatment are very real. What follows are a few thoughts on the statements, responses and few interesting links. Some thoughts from GP peer review.

 Consensus Statement 1: For men aged 50–69, level 1 evidence demonstrates that PSA testing reduces prostate cancer-specific mortality and the incidence of metastatic prostate cancer.

This statement is really a push back against the US Preventive Services Task Force recommendation. The evidence base is mixed but that screen reduces the mortality and risk of metastases  at diagnosis is fairly clear . What is unclear is how much harm this screening and treatment causes. Interestingly within the statements there is no mention of harms which leads to Statement 2.

 Consensus Statement 2: Prostate cancer diagnosis must be uncoupled from prostate cancer intervention.

 This is an attempt to reduce the harms that over diagnosis and treatment cause currently. The GPs at peer review thought this aspirational statement was excellent but still remained cynical about how much this was currently occurring.

The reality that PSA testing drives a large portion of private urology work/referrals does make some uncomfortable.

 I would point you in the direction of Dr Rajiv Singal who wrote an excellent piece on this in June. (@DrRKSingal)

“In my view PSA itself is a blood test. It is harmless. It is the treatment machinery that it often initiates that potentially gives it a bite and needs careful reflection.”

Consensus Statement 3: PSA testing should not be considered on its own, but rather as part of a multivariable approach to early prostate cancer detection.

There are currently multiple risk assessment tools but little consensus around their use. This also reflects the benefit of DRE in addition to PSA testing. 

 Consensus Statement 4: Baseline PSA testing for men in their 40s is useful for predicting the future risk of prostate cancer.

I understand the reasons for this statement but the application of it which I have seen discussed confuses me. If someone is very low risk for prostate Ca in their 40s and make up less than 10% of prostate cancer diagnoses when followed up why would you continue to screen them in 5-7 years or again at all?

 Consensus Statement 5: Older men in good health with over ten year life expectancy should not be denied PSA testing on the basis of their age.

I found this interestingly nonspecific which I guess is the point. The risks of overdiagosis do need to be stressed more than with younger patients. Also the benefit is unclear as patients age beyond 70.

“Dr. Patrick Walsh, the noted Johns Hopkins urologist and forceful advocate for prostate cancer screening, famously (and humorously) said that he would not do a PSA test on a man older than 75 unless he was brought to the office by both his parents.”


 Media discussion:

The media uptake of the consensus statement has been pretty impressive. All the major networks picking up the story and print media have also followed suit. Unfortunately the stories have been one sided and this may be a “necessary evil” but the reality is this document will be seen as the prostate cancer experts giving their opinion on screening even if that is not the stated intention.

“ONE of the world’s greatest medical debates has come to an end with experts  agreeing that men should start testing for prostate cancer in their 40s.”

Read more:

 You tube video of the media response:

From some of the comments from the BJUI website:

Associate Professor Ian Haines clearly not convinced of the merits of the document:

“This appears to be a pointless, self-serving, unbalanced, unhelpful piece of ‘propaganda’ by a self-selected group of like-minded urologists with huge financial conflicts of interest. It seems no more useful than a group of 10 pig-farmers telling us that we should eat more bacon.”

I am comforted by the comments of Mike Leveridge

“We have doubtless all had patients developing cynical approaches to PSA testing based on what they have seem and read recently, and it is nice to see this side of the debate register some air time (one caveat might be the promulgation of sensational headlines: The Australian: “Prostate experts end PSA test confusion”; I think Bloomberg’s “Prostate Test Warrants Rational Use” is much more becoming of the discipline, but I suppose we can indulge some rabble-rousing if it draws attention to the message).”

 A final thought will be left to Minh le Cong who left a comment which I think reflects the thoughts of myself and the other GPs at my peer review:
“Like other commenters, I don’t totally agree with some of the claims in the statement. However the spirit of the statement is on moving forward and changing our strategic thinking on prostate cancer/health. We should all be supporting that spirit.”



  1. A/Prof Henry Woo says:

    Great to seeing the topic being discussed. The discussion that follows the BJUI on line publication of the Melbournce Consensus Statement is of particular interest. Debate has been polarised between those concerned about the high mortality and morbidity associated with prostate cancer (supporting screening) and those who are concerned about the overdiagnosis and overtreatment with consequent complications associated with prostate cancer (against screening). We all know the real answer lies somewhere in between. Supporters of screening have recognised the shortcomings of screening and moved sharply towards smarter selection for testing, smarter selection for biopsy and a more conservative approach to clinically insignificant prostate cancer. Urologists have also become a lot smarter about managing the side effects associated with treatment. The Consensus Statement is not a call for screening or a set of guidelines – it tries to make sense of the latest data and assists individual (not population management) decision making with regard to whether they wish to be tested or not. Those who oppose screening continue to steadfastly maintain their position and continue to ignore the large numbers of men who die from prostate cancer each year. The answer to this debate does not lie at the extreme ends of opinion and it is about time that anti-screening detractors think about moving to a more moderate view.

    • Thanks for your comments A/prof Woo,
      Couldn’t agree with you more in regards to the middle ground being the likely best answer. Sadly the middle ground has been a casualty of the scorched earth approaches of both extremes. Most locals here do PSA starting at 50 if pts request but longer interval than annual or even biannually.
      As a slightly younger bloke I’m hopeful for a new marker before my time comes.

  2. thanks Andre, great article!
    I held an impromptu clinical meeting with a bunch of mostly male GP colleagues yesterday to discuss the Melbourne consensus statement.
    We have professional and indeed personal interest in getting this as right as we can!
    Our discussion and sometimes debate concluded that in the end we dont want overtreatment and overanxiety producing practice. Equally we do want to reduce prostate cancer mortality and morbidity.

    One colleague pointed out the morbidity produced with anxiety with the diagnosis of prostate cancer, albeit even a low grade one. The act of adopting active surveillance may not necessarily be as reassuring as we might hope and in fact produces more anxiety and maybe more morbidity if repeated biopsies are needed in a surveillance program.

    We liked the idea of doing screening PSA at 40yo , 50yo and 60 yo for the individual man who is interested in prostate health care and at risk of cancer i.e FMHx etc.

    Another colleague decried the arguement that older men should not be screened for prostate cancer on the basis that they will die from something else. He pointed out that with men living longer, this was becoming an increasingly unjustified nihilistic argument.

    The reality we all admitted is that if a man came in requesting a PSA, in general we would all order one after counselling the patient. What we have moved away from has been the annual PSA that was seemingly so popular a few years ago, and this statement supports the notion of infrequent and selective testing.

    We have been encouraged by the Melbourne statement spirit that if the PSA is abnormal, then referring the patient to a urologist from now on , one of the recommended main strategies will include active surveillance and not immediate surgery etc. We look forward to the urology community in demonstrating a robust and safe program of surveillance.

    • Thanks for your thoughts Minh,
      The anxiety is a difficult one as patients reaction to watchful waiting/active surveillance are hard to predict.
      Still see quite a few here with elevated PSA from their mining occupational health annual PSA tests (starting at 35!) but have chased and hopefully will be modifying the process and consenting which was not happening previously!
      I agree that if GPs felt more comfortable with the urologists having a watchful waiting strategy most would feel much more comfortable with PSA.
      Statement 2 really shows that urologists are acutely aware of this.
      As always look forward to your PSA podcast :)

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