Prostate cancer testing

How can I test for prostate cancer?

The most common test to indicate if you have issues with your prostate, is a prostate-specific antigen (PSA) blood test.

Prostate specific antigen (PSA) is a protein made in the prostate gland. The prostate is a walnut-sized gland that sits below the bladder in front of the rectum. It surrounds the urethra, the passage in the penis through which urine and semen pass.

PSA is produced by prostate cells and enters the blood stream. As men get older and the prostate gland grows larger, they may produce higher levels of PSA.

The prostate specific antigen (PSA) test is the blood test used to detect an increased risk of prostate cancer. Higher than normal levels indicate that you may have an issue with your prostate that requires further testing.

What other factors can influence PSA levels?

Higher levels of PSA do not always mean you have prostate cancer. Increased levels can also be caused by other conditions like prostatitis, an infection in the prostate. An elevated PSA level means something is happening in the prostate gland and further investigation may be required.

Should I have a PSA test?

Prostate cancer is the most common cancer in Australian men. Each year, approximately 26,000 men will be diagnosed with prostate cancer and around 3,900 will die from it.
Current guidelines recommend that men over age 50, or over the age of 40 with a family history of prostate cancer, should talk to their doctor about testing for prostate cancer as part of their regular health check-ups.

Prostate cancer often has no symptoms in its earliest stage. If someone does have symptoms, they should speak with their GP immediately. These include:

• urinary symptoms including frequent urination at night, poor urine stream, dribbling at the end of passing urine, or slow to start the urine flow
• blood in the semen or urine – never ignore this symptom
• pain on urination or ejaculation
• back or pelvic pain.

It is important that you make an informed decision about testing based on the latest available evidence on the benefits and potential harms of testing and subsequent treatment for prostate cancer.

What are the potential benefits of PSA testing?

• PSA testing can reduce a man’s risk of dying from prostate cancer.
• In a man with no symptoms, PSA testing can detect a potentially harmful cancer before it spreads.
• Early detection and treatment of a harmful cancer increases the chance it can be cured.
• If you are concerned about prostate cancer, regular PSA testing can put your mind at rest.

Your doctor should fully explain your risk factors and the potential benefits and possible harms of testing before you make your decision. It is important to ask lots of questions, so you clearly understand what PSA testing involves and what happens next if your PSA result is normal or elevated.

What are the possible harms of PSA testing?

• You may get a false positive result where your PSA levels are high, but you don’t have cancer. This and the extra testing required can cause worry, distress and physical side effects (if a biopsy is needed).
• PSA levels may not be elevated in some men who have cancer and the cancer may be missed. This is called a false negative.
• PSA testing can detect cancers that may not be harmful or life-threatening, leading to anxiety and potentially unnecessary treatment.
• Doctors cannot be sure which cancers will be harmless, even after further checks and examination. Therefore, either Active Surveillance or treatment is recommended. So, across all the men who have PSA testing, some end up having Active Surveillance or treatment they may not need.

What do the results mean?

A PSA level that stays elevated suggests something is going on in the prostate and further tests are required to determine if it is cancer or something else.

If your PSA level is over 3.0 ng/ml, your PSA test should be repeated within 1 to 3 months. This is because the PSA sometimes returns to normal levels. Your doctor may also order a free to total PSA ratio test. If the PSA is still elevated and the free to total ratio is low, then you may be referred to a specialist (urologist) for more tests.

If you have a family history of prostate cancer and/or are aged in your 40s, your doctor may recommend further PSA testing if your PSA level is above 2.0 ng/ml.

An abnormal PSA result does not necessarily mean you have prostate cancer.

What are the next steps?

Your doctor will consider the results of your repeat PSA test, as well as your age and family history before recommending the next steps for you.

If your repeat PSA results are not cause for concern, talk to your doctor about future PSA testing.

If your repeat PSA results still indicate a concern, your doctor will refer you to a urologist for further investigations.

The urologist will perform a number of tests to confirm if you have prostate cancer.

As part of their investigation, this may sometimes include a digital rectal examination (DRE). This is a procedure where a specialist inserts a gloved, lubricated finger into the rectum to feel the size and shape of the prostate gland. A normal DRE result does not necessarily rule out prostate cancer.
More commonly, one of the following are used:

Magnetic resonance imaging (MRI): This is a scan to assess the size of the prostate and look for any abnormal areas. An MRI helps to identify an area that may require a tissue biopsy and rates the risk of finding a cancer that requires treatment. This helps the urologist to decide whether a biopsy is needed and which area of the prostate to target for the biopsy.

Biopsy: This is a procedure where a needle is used to remove multiple small samples of tissue from the prostate gland. The samples are sent to a laboratory to be examined. This will show whether the cells in the prostate are malignant (cancerous) or benign (non-cancerous). A biopsy is the only way a definitive diagnosis of prostate cancer can be made. A biopsy can be performed either through the rectum under local anaesthetic or through the perineum under anaesthetic.

If the biopsy shows that there is cancer present, a medical specialist (such as a urologist or a radiation oncologist) may recommend a PSMA PET scan if your cancer is intermediate or higher risk.

If the biopsy is negative, you will probably be offered routine monitoring of your PSA levels. If subsequent tests show a rise in PSA levels, you may need another biopsy or MRI scan.

PSMA PET/CT. In Australia, the PSMA-PET/CT scan is mainly recommended if you have been diagnosed with intermediate or high-risk prostate cancer and want to check that it has stayed within the prostate (localised) or spread. This is a new and specialist technology that has been shown to be the most accurate scan for staging prostate cancer.

Monitoring prostate cancer

After a diagnosis of cancer, regular PSA blood tests are used to monitor the cancer activity in a man’s body. Generally, prostate cancer causes PSA levels in the blood to get higher as the tumour grows. Regular blood tests can indicate whether the tumour is shrinking or enlarging, and whether the current treatment is working or not.

There is currently a review of the PSA test guidelines underway and new guidelines may result from this review.

Where to get help

• Your GP (doctor)
• Urology specialist
• Prostate Cancer Foundation of Australia. Tel. 1800 22 00 99
• Healthy Male- Prostate cancer treatment
• Cancer Council Australia
• Cancer Council Victoria Helpline, which can link you to prostate cancer support groups Tel. 13 11 20
• Multilingual Cancer Information Line, Victoria Tel. 13 14 50
• WeCan website helps people affected by cancer find the information, resources and support services they may need following a diagnosis of cancer.
• MensLine Australia
• Beyond Blue
• Lifeline Australia