Source: The Conversation (Au and NZ)
Prostate cancer is common. About 200 in every 1,000 Australian men will be told they have prostate cancer by the age of 85. But the chance of dying from it is much lower: around 18 in 1,000 cases.
Prostate-specific antigen (PSA) blood testing remains the most widely used test to detect prostate cancer – but it’s far from perfect.
The first update to Australia’s PSA testing guidelines in a decade now recommends men aged 50 to 69 consider having a PSA test every two years.
Those aged 45 to 50 and over 70 may be eligible for a test but should talk to their GP about the potential risks and benefits, and their individual circumstances.
Rectal examinations are not routinely recommended alongside PSA tests.
How does PSA testing work?
PSA is a protein made by the prostate gland. It liquefies the ejaculate in semen so sperm can swim. A small amount leaks into the bloodstream, and a PSA test measures how much.
Men’s prostates produce different baseline levels of PSA. This is partly due to genes, which explain up to 16% of the differences in PSA between men.
Total PSA greater than 3.0 nanograms per milliliter (ng/mL) is considered an elevated PSA level in the guidelines for men 50 to 69.
PSA is a prostate test, not a cancer test. Any breakdown in the cells of the prostate can make it leak. A raised result could mean prostate cancer. Or it could mean a benign (non-cancerous) enlarged prostate, an inflamed prostate, or an infection.
The point of the test is to catch a dangerous cancer while it is still inside the prostate and still curable. But some cancers produce very little PSA, so a normal result cannot completely rule cancer out. And the PSA test cannot tell a dangerous cancer from a harmless one.
What do the guidelines say?
The 2026 guidelines say GPs should raise the possibility of having a PSA test with eligible men. The GP should explain the benefits and harms, and the man should decide whether to have the test.
Under these guidelines, routine PSA testing is not recommended for men (and others with a prostate) under 45 who are at average risk.
Men at higher risk should undergo testing every two years starting at age 45. Higher‑risk status includes having a confirmed harmful BRCA2 variant, a brother with prostate cancer, a father diagnosed before age 65, two or more second-degree relatives who died from prostate cancer, or Black sub‑Saharan African ancestry.
For men at average risk, the new guidelines recommend:
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age 45–49: one optional baseline test after discussing the pros and cons. This doesn’t mean every 45-year-old should be screened every two years. It simply means a man who is interested can get a baseline reading. This may help detect elevated PSA levels later on
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age 50–69: GPs offer testing every two years after an informed discussion of the pros and cons
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70 and over: an individual decision about what’s right for the patient. It may be considered worthwhile if his life expectancy is more than seven years.
PSA testing recommendations for Aboriginal and Torres Strait Islander men are the same as for the general population.
If your levels appear elevated, or they’ve increased above your baseline, you will be asked to take repeat test and, depending on the levels, may be referred for an MRI.
If cancer is suspected, you will be sent for a biopsy, where tissue is removed and studied in a lab for signs of cancer.
What are the potential benefits?
In one study over 30 years, 82% of lethal prostate cancers occurred in men with baseline PSA above the average for their age, indicating the benefit of measuring baseline PSA.
A recent Cochrane review of the existing data involving almost 800,000 participants worldwide concluded that PSA screening prevented about two prostate cancer deaths per 1,000 men screened.
This review found 1,000 PSA tests prevented around five metastatic cancers (that would have spread to another part of the body).
What are the potential harms?
The first is a false positive. This means a raised PSA in a man who doesn’t have cancer. This can cause worry, repeat tests – and sometimes a biopsy – all for nothing.
The second potential harm is overdiagnosis. This means finding a genuine cancer that would never have caused symptoms or shortened your life. A 15-year trial estimated roughly one in six cancers found through one-off screening was overdiagnosed.
Overdiagnosis turns into over-treatment if that harmless cancer is then treated. Surgery, androgen deprivation therapy and even radiotherapy can leave lasting urinary, bowel and sexual problems.
The third is a false negative. A PSA result can fall within the normal range even when prostate cancer is present. This may provide false reassurance and delay further investigation, particularly when symptoms, family history or other risk factors suggest that something may be wrong.
‘Watchful waiting’ tries to avoid over-treatment
Under current guidelines, Urologists often manage low-risk prostate cancers with active surveillance, also known as watchful waiting, rather than immediate treatment.
These cancers often grow very slowly and don’t cause any pain or other symptoms, and can be safely monitored. Patients on active surveillance are monitored every three months with PSA measurements and a physical examination every six months.
This shift towards watchful waiting is also why it has become standard to undergo an MRI before a more invasive biopsy. In one trial, 28% of men in the MRI-first group avoided a biopsy altogether.
What does this mean for me?
No matter your age, your GP can talk you through the potential benefits and risks for your age group, risk profile and situation. They can explain what might happen next, the chance of false positives, and the concept of watchful waiting.
Perhaps the most useful question to ask yourself before deciding to a blood test is whether you would actually be willing to have an MRI or a biopsy if the number came back high. If the answer is no, the test may have little to offer you.
Finally, remember that these age thresholds are for men without symptoms. If you have blood in your urine or semen, new urinary problems, or unexplained pelvic or bone pain, see your doctor.
Jyotsna Batra receives funding from the National Health and Medical Research Council, the Australian Research Council and the Prostate Cancer Foundation of Australia (for research into inherited pathogenic mutations in prostate cancer).
Original source: https://analysis1.mil-osi.com/2026/09/22/should-you-get-a-psa-test-for-prostate-cancer/