PSA testing in primary care: is it time to change our practice?

Abstract

Background: Historical prostate-specific antigen (PSA)-based screening studies reduced prostate cancer-related deaths but also led to overdiagnosis/overtreatment. Since then, opportunistic PSA testing has increased, and late-stage diagnoses and prostate-cancer related deaths are rising.

Objectives: To review current trends regarding PSA testing in primary care and propose a collaborative approach to improve early prostate cancer detection.

Discussion: Opportunistic PSA testing patterns vary among General Practitioners (GPs) and Family Doctors (FDs) based on differing guidelines, patient pressure, time constraints and personal views/preferences. However, an organised, risk-adapted strategy, as outlined by the European Association of Urology's guidelines, could facilitate the early diagnosis of significant prostate cancer whilst sparing those unlikely to experience disease-related symptoms from further tests (overdiagnosis) as well as the psychosocial consequences of a cancer diagnosis. This could be achieved by the introduction of national prostate cancer screening programmes, which has been endorsed in the European Commission's publication of the EU Cancer Screening Recommendations. In this scenario, GPs/FDs would still play an important role in supporting men throughout the decision pathway. However, as some men may still request a PSA test from their GP/FD, patient information as well as clear guidance and support to GPs/FDs are needed, including appropriate skills training to facilitate effective counselling and informed decision-making, and the use of risk calculators to inform referral decisions.

Conclusion: GPs/FDs play an important role in counselling healthy men eligible to consider PSA testing. However, clear guidance, training and support is required for them to assume this role.

Keywords: Primary care; Prostate cancer; Prostate-specific antigen; Screening.

Fig. 1

Risk-adapted algorithm for the early detection of prostate cancer, adapted based on prostate cancer guidelines published by the EAU [22, 23]. *Healthy men with a life expectancy of ≥ 10–15 years AND > 50 years of age OR > 45 years of age with a family history of prostate cancer OR > 45 years of age of African descent OR > 40 years of age carrying BRCA2 mutations. ^†The patient’s values and preferences should always be taken into account as part of a shared decision-making process [22].^‡ Includes repeat PSA testing after 2–4 years for PSA 1–3 ng/mL or after 5 years for PSA < 1 ng/mL; stop PSA testing in men > 60 years of age with a PSA < 1 ng/mL. EAU, European Association of Urology; mpMRI, multiparametric magnetic resonance imaging; PIRADS, Prostate Imaging-Reporting and Data System; PSA, prostate-specific antigen. [NOTE: Copyright permission attached to submission]