The PSA Test: A Simple Blood Test, A Complicated Decision

Background

If you're a man approaching 50, you’ve likely heard about the PSA test. With over 25,000 Australian men diagnosed with prostate cancer each year and around 3,700 dying from it, it's a health topic worth understanding. The prostate-specific antigen (PSA) test is a simple blood test that can detect the risk of prostate cancer early, often before any symptoms appear. However, deciding whether to have this test is not as straightforward as it seems. For decades, experts have debated its benefits and harms, which is why there's no national screening program for it like there is for breast or bowel cancer. This guide is designed to walk you through the pros, the cons, and the latest recommendations, so you can have a confident conversation with your doctor and make a choice that’s right for you.

What Exactly is the PSA Test?

The prostate gland produces a protein called prostate-specific antigen (PSA). A PSA test simply measures the level of this protein in your blood. A high PSA level can be a sign of prostate cancer, but it’s not a definite diagnosis. Other common, non-cancerous conditions can also raise your PSA levels, including:

• A benign (non-cancerous) enlarged prostate

• Inflammation or infection of the prostate (prostatitis)

• A recent urinary tract infection

• Even vigorous exercise or sexual activity before the test

Because of this, a high result can lead to a chain of follow-up tests and decisions, each with its own set of benefits and risks.

The Great Debate: Weighing the Benefits and Harms

The core of the issue is balancing the potential to save a life against the risk of causing unnecessary harm and anxiety.

The Case for Testing (The Potential Benefits)

• It Can Save Lives: Finding an aggressive prostate cancer early, before it spreads, significantly increases the chance it can be cured.

• Peace of Mind: For men worried about prostate cancer, a normal PSA test result can be very reassuring.

• Better Treatment Pathways: The process is no longer just a blood test and a biopsy. Modern methods like MRI scans help doctors identify which men truly need further investigation, reducing unnecessary procedures.

• "Active Surveillance" is Now Common: If a low-risk, slow-growing cancer is found, the new standard is often "active surveillance." This means your doctor monitors the cancer with regular tests rather than rushing into treatment, helping you avoid the side effects of treating a cancer that may never have harmed you.

The Case Against Testing (The Potential Harms)

• Over-Diagnosis: This is the biggest concern. PSA testing is very good at finding cancer, including many slow-growing, "harmless" cancers that would never have caused any problems. Finding these cancers is called over-diagnosis.

• False Positives & Anxiety: A high PSA result when no cancer is present (a false positive) can cause significant worry and lead to a cascade of extra tests.

• Risks of Follow-Up Tests: The only way to definitively diagnose prostate cancer is with a biopsy, an invasive procedure where tissue samples are taken. While much safer now, a biopsy can have side effects like bleeding, infection, and temporary urinary or erectile problems.

• Risks of Overtreatment: Because it can be hard to be certain which cancers are harmless, some men may end up having treatment they don't need. Treatments like surgery and radiation can have permanent side effects, including erectile dysfunction (impotence) and urinary incontinence.

What Happens if My PSA is High?

It's important to know that a high PSA level today doesn’t automatically mean a biopsy. The process is much more refined:

• Step 1: Repeat the Test: Your doctor will likely repeat the test in 1-3 months to confirm the result.

• Step 2: MRI Scan: If the level is still high, a non-invasive MRI scan is often the next step. This scan is very good at identifying aggressive cancers and helps your doctor decide if a biopsy is truly necessary.

• Step 3: A Safer Biopsy: If a biopsy is needed, it is now commonly done through the skin (a transperineal biopsy), which has a much lower risk of serious infection.

• Step 4: Active Surveillance: If a low-risk cancer is found, active surveillance is often recommended, protecting you from unnecessary treatment.

So, What Should You Do? A Personal Choice Based on Guidelines

There is no single right answer. The decision to test is a personal one that you should make in partnership with your GP.

Official recommendations suggest:

• Men should have a conversation with their doctor about testing every two years from age 50 up to age 69.

• If you have a family history of prostate cancer (a father or brother diagnosed), you should start this discussion even earlier, from age 40 or 45.

• For men aged 70 and over, the potential harms of testing may outweigh the benefits.

This advice is for men without symptoms. If you have any of the following symptoms, you should see your doctor right away, as a PSA test is recommended:

• Difficulty with urination (a weak stream, frequent urination at night, dribbling)

• Blood in your urine or semen

• Pain during urination or ejaculation

• New back or pelvic pain

The path from a simple blood test to a final decision is now much safer and more patient-focused than ever before. The most important step is the first one: starting the conversation with your doctor.

References

1. Gattellari, M., & Ward, J. E. (2003). PSA: Pros and cons. Australian Family Physician, 32(6), 429-430.

2. Prostate Cancer Foundation of Australia. (n.d.). Should I have a PSA test? [Pamphlet].

3. Rashid, P., Zargar-Shoshtari, K., & Ranasinghe, W. (2023). Prostate-specific antigen testing for prostate cancer: Time to reconsider the approach to screening. Australian Journal of General Practice, 52(3), 91-95.

4. Royal Australian College of General Practitioners. (2015). Should I have prostate cancer screening?

5. The Royal College of Pathologists of Australasia. (2022). Guideline: PSA Test Reporting.

6. Thirumavalavan, N., & Rascati, M. (2023). Prostate Specific Antigen. In StatPearls. StatPearls Publishing.

Does this sound more like you?

• You are very worried about prostate cancer and a test would reassure you.

• You would rather know if you had cancer, even if it might never cause you problems.

• You believe it’s better to be "safe than sorry" and accept the risks for the potential benefit of finding cancer early.

  If so, you might lean towards having a PSA test.

Or does this sound more like you?

• You are not currently worried about prostate cancer.

• You don't want to risk finding a "harmless" cancer that could lead to unnecessary treatment and side effects.

• You don't want to risk your quality of life for a possible, but not guaranteed, chance of living longer.

If so, you might consider not having the test at this time.