Volume 199 - Issue 10
Liaise with pathologists to refine understanding of the prostate-specific antigen test
Authors: Kenneth A Sikaris, Bronwen A Ross and Teck Y Khong
Med J Aust 2013; 199 (10): 656-658. || doi: 10.5694/mja13.10883
Published online: 18 November 2013
Published online: 18 November 2013
The PSA test is an important clinical tool that must be considered in its correct context.
To the Editor: Prostate-specific antigen (PSA) testing and prostate cancer, the focus of a number of recent articles in the Journal and a widely debated topic, are also the subject of an imminent position paper by the National Health and Medical Research Council (NHMRC). Given that there is general agreement on the potential for overdiagnosis and overtreatment of prostate cancer, it is important to continue our efforts to identify high-risk patients and patients for whom treatment is beneficial. The tools we have for this are the digital rectal examination, the PSA test and its refinements, and biopsy with Gleason scoring and its refinements.
The PSA test is a widely misunderstood measure for determining prostate cancer risk. Many authors seek to dismiss its value without careful analysis of recent advances, or acknowledgement that past research often has limited current relevance. For example, the article by Del Mar and colleagues acknowledges PSA free-to-total ratios and the rate of increase in PSA,1 but makes no mention of age-related cut-offs, which is the method of refining utility of PSA testing.2 The article by Hugosson and Carlsson3 is well balanced and highlights the problems in trying to compare the evidence from four inadequate PSA screening studies and one well conducted study (ERSPC [European Randomized Study of Screening for Prostate Cancer]). Martin and colleagues attempt to study the cost effectiveness of PSA screening using a PSA cut-off of 4 ng/mL,4 despite the fact that all Australian laboratories should be using age-related cut-offs. Further, Martin et al ascribe a test cost for PSA testing of $37.55, which includes the cost for the measurement of multiple PSA fractions, even though these were not used in the screening trials
Pathologists and medical laboratory staff operate behind the scenes but seek to give referring doctors and their patients the best possible information in making clinical decisions about their care. The Royal College of Pathologists of Australasia has produced a position statement to assist in placing the PSA test, a useful clinical tool, in its correct context.5 Pathologists are also involved in the current national initiatives of the NHMRC and Prostate Cancer Foundation of Australia, which weexpect will provide balanced and helpful advice for clinicians and their patients.
Competing interests
No relevant disclosures.
References
- Del Mar CB, Glasziou PP, Hirst GH, et al. Should we screen for prostate cancer? A re-examination of the evidence. Med J Aust 2013; 198: 525-527. 0_CBBJDICG
- McKenzie PR, Delahunt B, Kench JG, et al. Prostate specific antigen testing: age-related interpretation in early prostate cancer detection. Pathology 2013; 45: 343-345. 0_CBBBDADI
- Hugosson J, Carlsson SV. The dilemmas of prostate cancer screening. Med J Aust 2013; 198: 528-529. 0_i1142872
- Martin AJ, Lord SJ, Verry HE, et al. Risk assessment to guide prostate cancer screening decisions: a cost-effectiveness analysis. Med J Aust 2013; 198: 546-550. 0_i1142876
- Royal College of Pathologists of Australasia. Position statement. Prostate specific antigen testing: age-related interpretation in early prostate cancer detection. http://www.rcpa.edu.au//static/File/Asset%20library/public%20documents/Policy%20Manual/Position%20Statements/PSA%20Statement.pdf (accessed Aug 2013).