Mayo Urology Centre, Taree

The Urological Society of Australia and New Zealand (USANZ) issued the following media release on 23 September 2009.

Prostate cancer test age lowered to 40

The age at which men are recommended to first have a test to help identify prostate cancer has been reduced from 50 to 40 years of age.

This test should be done after the patient has been advised by the doctor of the benefits and potential consequences of testing for prostate cancer, including the risk of the detection of cancers which may not require immediate treatment.

The recommendation from the Urological Society of Australia and New Zealand (USANZ), which is the peak body for urological surgeons in both countries, is based on evidence that the earlier diagnosis of prostate cancer will reduce the risk of death from the disease.

USANZ says men should first undergo a simple physical examination and blood test at or beyond the age of 40, due to increased awareness of men younger than 50 being diagnosed with prostate cancer, and the publication of medical studies demonstrating a better prognosis if prostate cancer is picked up earlier.

Not all men will require immediate treatment with “active surveillance” being appropriate in many cases in the short to medium term. This means the patient is monitored by regular tests and examinations but the cancer is not immediately treated.

Each week more than 10 men under the age of 50 will be diagnosed with prostate cancer in Australia and New Zealand. USANZ recommends that men aged 40 years or older undergo an initial Prostate Specific Antigen (PSA) blood test following consultation with their GP or urologist which will help to stratify them into risk categories, based on the test results.

“The future risk of prostate cancer is closely related to a man’s PSA level; a baseline PSA level above the median for age 40 is a predictor for prostate cancer. Such testing may not only allow for the earlier detection of more curable cancers, but may also allow for more efficient, less frequent testing”, said USANZ President, Dr David Malouf.

“GPs should be offering a PSA test to 40 year old men in conjunction with a digital rectal examination (DRE) after discussing with them the subsequent potential issues.

“Those identified as being at higher risk should undergo regular tests; those at low risk should consider less frequent testing.

“A PSA level higher than 0.6 in a 40 year old is considered higher risk, as is a level of higher than 0.7 in a 50 year old, and regular monitoring is recommended for these groups.

“There is firm data that PSA testing reduces the risk of being diagnosed with advanced disease, and that treatment of prostate cancer at an early stage can lead to a reduced risk of death.

“If we continue to wait until men are 50 before being tested, we will miss some with prostate cancer who could have been identified much earlier, monitored by their GPs and urologists and received timely appropriate advice and treatment. These men have a better prognosis if they are picked up earlier.

“There is now strong evidence that having a baseline PSA test at age 40 is a smart move which can help determine whether a man is in a low risk or high risk category and enabling appropriate follow-up to occur”, Dr Malouf said.

USANZ advises that other factors such as family history of prostate cancer, age, overall health and ethnicity should be combined with the results of PSA testing and physical examination in order to better determine the risk of prostate cancer.

“Prostate cancer testing at any age remains an individual decision that men should make in full consultation with their GP and urologist”, Dr. Malouf said.

USANZ’s PSA testing policy can be downloaded in PDF format from http://www.usanz.org.au/uploads/29168/ufiles/USANZ_2009_PSA_Testing_Policy_Final1.pdf

The Prostate Cancer gene 3 (PCA3) Assay is a new gene-based test. One should understand that it is yet not a replacement for prostate specific antigen (PSA) testing.

A PSA test reading between 4 to 10ng/ml could be considered “Surgeon’s Graveyard”. On number of occasions it becomes extremely challenging to decide whether a particular patient with his PSA falling in this range would need a biopsy. Urologists use various tools such as PSA density and PSA velocity to avoid unnecessary prostate biopsies. But these tools are still not reliable. Researchers have been on a quest of finding such a non invasive test which would predict an abnormal PSA level from underlying prostate cancer and that to with certainty.

The PCA 3 test is a step towards this goal.

PCA3 is, unlike PSA, prostate cancer specific. This means that it is only produced by cancerous prostate cells and not affected by prostate size. It discriminates better than PSA between PCa and benign/non-cancerous prostate diseases such as benign prostatic hyperplasia (BPH, i.e. prostate enlargement) or prostatitis (infection of the prostate). Therefore, PCA3 gives very useful information, in addition to PSA, in deciding if biopsy is really needed. A high PCA3 Score indicates an increased likelihood of a positive biopsy, i.e. presence of cancer cells in the prostate. A low PCA3 Score indicates a decreased likelihood of a positive biopsy. A recent study suggests that the PCA3 Score can also differentiate between non-significant (indolent) and significant Prostate cancer.

Interpretation of the PCA3 test result

The PCA3 Assay is a simple test: following a digital rectal examination (DRE), cancerous cells with high levels of PCA3 are shed from the prostate into the urine. A urine sample is then collected . This urine sample is sent to a laboratory for determining the PCA3 Score. If the PCA3 Score is low, a biopsy may be delayed or eventually avoided. In this way, the PCA3 Assay may help to avoid many unnecessary first biopsies and the potential discomfort and complications (pain, bleeding and infections) for the men involved.

The PCA3 Assay can also be used in men with one or more previous negative biopsies to predict the likelihood that another biopsy will be positive, or in other words to assess the need for a next biopsy.

If a biopsy is performed and turns out to be positive, the PCA3 Score may be used as complementary information in predicting the pre-operative risk of PCa progression and the need for early treatment.

This test is still in its research stage and cannot be considered as an established tool for diagnosing prostate cancer.

Not all patients qualify for this test. Patients who may not qualify for this test:
Whose PSA is > 10ngs/ml,
who have abnormal prostate examination,
abnormal PSA (regardless of its level) and have family history of prostate cancer

Where is it available?

Presently, this test is available in places like Sydney, Melbourne and other metropolitan cities across Australia.

More technical information

http://www.prostate-cancer.org/education/preclin/Torres_PCA3.html