New guidelines are here. The Prostate Cancer Foundation of Australia and the Australian Government Department of Health, Disability and Ageing have released the 2026 Guidelines for the Early Detection of Prostate Cancer. One in seven Australian men will be diagnosed with prostate cancer. The aim is to find early prostate cancer in the men most at risk, while sparing low-risk men tests they do not need.
The story starts in forensic science. In the 1960s, crime labs needed a better way to detect semen than finding sperm, which break down within minutes to an hour. Dr Travis Brown explains how the Japanese forensic scientist Mitsuhara identified a protein he called gamma-seminoprotein. Teams at Cornell and the University of California found the same protein under other names. Today we call it PSA. By the 1970s, researchers saw it was raised in advanced prostate cancer, and its long, debated path as a screening test began.
The last guidelines came out in 2016. Since then, two things have shifted the balance of risk and benefit: access to multiparametric MRI, and the move from transrectal to transperineal biopsy. In this episode, Ken walks through the key changes:
- Free-to-total PSA ratio is no longer needed. MRI is better at sorting risk. About 80% of men with a confirmed PSA above 3 already have a free-to-total ratio below 25%.
- Ages 45 to 49 (higher risk): refer when PSA is above 1 ng/mL. This group includes men with a brother with prostate cancer, a father diagnosed at 65 or younger, or a BRCA mutation.
- Ages 50 to 69: the threshold stays at 3 ng/mL, or 2 ng/mL for higher-risk men.
- Ages 70 and over: for men likely to live more than seven years, the threshold is 5.5 ng/mL. Men below 5.5 can reasonably stop testing.
- Repeat the test in one to three months. About 30% of men with a PSA above 3 will test well below 3 on repeat, often due to BPH-related variation.
- GPs should now start the conversation. The 2016 guidelines had GPs respond when a man raised it. The new guidelines, endorsed by the RACGP, ask GPs to raise PSA testing with men aged 50 to 69.
Not for prostate cancer screening. In the evidence, rectal exams by non-specialists added as many false positives as false negatives. Ken notes that urologists still gain useful information from it, and a rectal exam remains relevant when you are looking for rectal cancer.
Men with a first-degree relative with prostate cancer, men with BRCA mutations, and men of African ancestry. The guidelines also name Aboriginal and Torres Strait Islander men as a priority population because of poorer access to care. Ken adds that men in regional Victoria have worse prostate cancer outcomes than men in the city.
This is the story of the 2026 Early Detection of Prostate Cancer.
Useful Link:
2026 Guidelines for the Early Detection of Prostate Cancer in Australia
Our Special Guest:
Professor Ken Sikaris is a chemical pathologist and head of clinical integration at Dorevitch Pathology. He is a NATA laboratory assessor, a founding fellow of the RCPA Faculty of Science and a principal examiner in pathology informatics. Ken was one of the first people to measure PSA in Australia, bringing in some of the first test kits around 1989. He helped write the new guidelines.
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Automated Transcript:
This transcript was generated automatically by Descript. I will contain errors and spelling mistakes, but is offered as a guide and resource to help AI and search tools discover the content on behalf of GPs, medical students, other allied health professionals, and the general public.
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Steve Davis: [00:00:00] Welcome to This Medical Life podcast. These are the stories of medicine with Steve Davis and Dr. Travis Brown. This is the story of the 2026 prostate cancer screening guidelines
Dr. Travis Brown, we have talked about prostate cancer screening many times before, um, and all the various tests, from the invasive ones to the blood tests, et cetera. Why are we on the topic again?
Dr Travis Brown: So these cancer guidelines have actually just been released. So this is by the, uh, Prostate Cancer Foundation of Australia and the Australian government.
Uh, and they’ve, uh, [00:01:00] released these guidelines just pretty much this, just the end of this year. Uh, and look, this is something that surprised me somewhat because I was just only stopped talking to GPs about, okay, we need prostate and free pro- free PSA, and this is how we do it. And so I feel like doctors have just gotten the handle on the previous guidelines as to testing and repeat testing, and now these guidelines come out, and I was like, oh, dear me.
We, uh, you know… But this is the, this is cancer screening and, you know, new guidelines come out all the time, and this was to, to review that. And so-
Steve Davis: It’s a good problem though, isn’t it? It means that we’ve taken a leap forward in our understanding, doesn’t it?
Dr Travis Brown: It is. And this is a whole bunch of experts have gotten, gotten together and say, okay, how can we refine this even further?
How do we actually detect people, uh, who have prostate cancer? Who do we need to detect? Who’s at risk? And so this is the part, this is where we’re actually looking at risk stratification. We’re looking at risk categories. We’re looking at people [00:02:00] and the ages we should test. Uh, there’s even flow charts, uh, as they always have, but now this has been refined as to who fits where.
This is important, and again, it comes back to PSA testing. Uh, so we’ve discussed this a, a fair bit in previous PSA testing, free PSA, which is an, an additional test. Uh, but if you look at PSA testing, it’s actually quite, uh… It’s just been an interesting evolution in testing. And, and this is the, uh, CSI, if you wanna talk about, you know, where PSA comes from.
A- and this was actually, it was in the 1960s, and, and it comes through mainly from forensics, and this was because forensic science was actually looking at crime scenes and trying to detect different bodily fluids that are about. Uh, and at the time, the way you determined if there was semen present at a crime scene, you had to find sperm.
Uh, and sperm [00:03:00] is not a good pro- to actually find. Sperm- They don’t last long, do they? No, don’t last long at all. Outside of the body, they can last anywhere from a few minutes to an hour if you’re lucky, uh, in the right environment, but it’s very easy to kill, very easy to, easy to destroy sperm. Uh, and so- Sperm is or was considered the gold standard, but so difficult that chances are you weren’t going to find it.
So there was a test that was available. It was called PAP. So this was prostatic acid phosphatase, uh, and- Not
Steve Davis: to be mistaken with the PAP pap smear.
Dr Travis Brown: No, pap smear, no, completely different. And so this is, uh, this was a test. It’s a chemical test that you would mix in a solution, uh, and it got a … If there was prostatic secretions present, uh, it would turn rapidly purple, like a, a very rapid purple ch- color change in that solution, and you would go, okay.
And the- what they called that was a presumptive positive. [00:04:00] And the reason it was presumptive was because other s- other bodily fluids also reacted. It could have this acid phosphatase in it. Uh, so, you know, urine, feces, blood, uh, vaginal secretions could actually have this reaction, but it was much slower.
And so you … There was a difference. It reacted quicker, but that’s why they called it a presumptive positive. The only problem is that’s not solid evidence. You know, someone’s interpretation of a rapid Color change could be somewhat subjective, so it wasn’t a great test.
Steve Davis: It would actually be great if you were, had that gin that when you add the tonic to it, turns purple- Right
uh, as a way of teaching students.
Dr Travis Brown: Yeah, well, so it’d be very good in universities in the ’50s and ’60s. Uh, but the forensic, there was a forensic sci- scientist who was from Japan, his name is Mitsuhara, and he went a- and investigated. He said, “Well, is there something better to actually find out if [00:05:00] this is, uh, you know, prostatic secretion or semen that’s present?”
And what he found was something that he called, he called it gamma semino- protein, and this was actually what we call today PSA. And about the same time, they had a, a number of other, uh, universities, it, this was in the United States, so there was Cornell University and University of California. They also found this same protein.
One of them called it E1, another one call it P30. And all it, what it came to be was it was the same protein, so we now know it today as PSA. Uh, now this is in normal secretions. Uh, but what they found in the 1970s is they started testing it just as a, as trials and found it was actually quite elevated in patients who had advanced prostatic cancer.
And so in the 1970s, they realized this, and this started a whole bunch of testing that happened in the ’70s and ’80s. Was [00:06:00] this a useful tumor marker?
Steve Davis: So that means criminals were the first beneficiaries- … of a prostate cancer-
Dr Travis Brown: Well, the gen- I would say the criminals was the, the tag of someone very, very intelligent to say, “Where can this go?”
But again, the reason why it was a problem is because it’s in normal secretions. This isn’t a very good tumor marker when it’s in normal. So that’s why it became very controversial is because it wasn’t just elevated in patients who had cancer, it was elevated in people who had any form of prostatic pathology.
Steve Davis: Yeah. I, I always associate it with false positives.
Dr Travis Brown: That’s right. And so when you, when we were looking at it in the ’80s and ’90s, even into the 2000s, this was a test that if you had four people who had an elevated PSA, three of them had it for benign circumstances or benign reasons. And so when you look at that, one in four patients having prostatic cancer, was that valid as a screening test?
Now, some people said yes, and some people said [00:07:00] no. The problem is, at the time- Those four people, the best test for that would’ve been a prostatic biopsy. Now, that comes with its own risks, its own challenges. There’s can be bleeding, infection, and so are you almost doing more harm than the screening test is for detection?
And so this was controversial. Uh, we have now gotten to the point where this has now been refined 30 or 40 years. Uh, we now have additional tests, so you’ll hear us call about a multiparametric, uh, MRI. And so there is actually a staggered process of us being able to detect who is actually, first of all, higher risk for prostatic cancer, who can have the MRI, and then who goes on to have the biopsy for further.
And so there is a stepwise procedure, and that’s why we’re discussing this today. And so these new guidelines tell us who is high risk, what is just normal, and who we can actually take [00:08:00] through to the next level, and this is why it’s, it’s useful for us to be s- discussing this today.
Steve Davis: Can we find out from our guest if we still need to have the digital exam?
Dr Travis Brown: Uh, I, I’ll leave that question to you, Steve.
Steve Davis: Professor Ken Tsokaris is a chemical pathologist and head of clinical insight at Dorovitch Pathology. Professor Tsokaris is a NATA-accredited laboratory assessor, founding fellow of the RCPA Faculty of Science, and a principal examiner in pathology informatics. He’s a fellow of the Department of Pathology at the University of Melbourne.
Ken, welcome back to This Medical Life.
Professor Ken Sikaris: Thank you, Steve. Hi, Travis. It’s great to be back.
Steve Davis: Let’s start with an easy question. Why did these guidelines come out, Ken?
Professor Ken Sikaris: Um, [00:09:00] that’s not an easy question. The c- the… Look, we needed new guidelines. The last guidelines were two thousand and sixteen, and in that period, there’s been some significant changes in the way that prostate cancer’s being managed.
And so the, the changes particularly are the, um, in Australia, the availability of, uh, multiparametric MRI for, um, assessing the likelihood of malignancy, as well as the shift to, from transrectal biopsy to transperineal biopsy has occurred in that period. So it’s changed the whole, uh, balance between risk-benefit in terms of, uh, prostate cancer testing.
Um, they’re the main reasons. There have been some updates on the, um, on the ERSPC study, the European Randomized Screening Study of Prostate Cancer, where they’ve got longer term outcomes, which have, you know, im- improved slightly [00:10:00] the initial, um, predictions. But the predominant things are the, the way that MRI and perineal biopsy have, has affected the risk, uh, profile for pr- PSA testing.
Dr Travis Brown: Now, I’ve only felt like I’ve just started finishing getting doctors to understand about PSA and free PSA. Yes. Uh, is, is this gui- are these guidelines simplifying things, or are they making them more complex, or is that integrated into it? What’s… Where is it
Professor Ken Sikaris: at? It’s simplifying things because, and Travis the, in the last guidelines, if you had a raised PSA above three, you had to confirm it with a raised, uh, uh, together with a poor prognostic low free to total ratio, and that was complicating the screening process that, you know, you had to now this second PSA test that had to be considered at the same time as the total PSA.
Because MRI is so superior to free to total [00:11:00] testing in differentiating risk, then the, the new guidelines said we don’t need it anymore. And not only that, um, the, um- If a, if a man has a PSA which is above three, confirmed above three, 80% of them have a free-to-total ratio of below 25% anyway. And so removing that guideline only increases testing by 20% and moves all of those men over to MRI testing, which is superior to those tests.
So it does simplify the guidelines because free-to-total is no longer required. And free-to-total, you know, as a screening test, had a limitation in Medicare, and patients had to agree to pay an extra amount of money to, but in case they needed the free-to-total. And, and so, and really, um, you know, with a lot of This testing, we don’t want to have these barriers, whether they’re financial or, [00:12:00] or psychological in, in a, you know, in cancer, searching for cancer.
So, yeah, the dropping it was because it didn’t add a lot, but it simplified the testing pathway to get rid of FREDA total.
Dr Travis Brown: So are these more European-based guidelines now, or sort of we’re basing it on studies out of Europe, or is, is
Professor Ken Sikaris: it out- It’s just out of the … Well, there were two, um, screen- randomized screening trials, so-called randomized.
Pretty hard to randomize because patients can still, can choose whether to get PSA testing or not, whether they’re in the control arm or not. But there were two studies, and one was in, one was in America, and, uh, and that one was really a failure because the arm that was supposed to have screening had screening, let’s say, something like 60% of the time, and the arm that wasn’t supposed to have screening had screening 40% of the time.
So it wasn’t like 100% versus [00:13:00] 0%. It was a very marginal difference. And, and not surprisingly, it didn’t have the power to show what the European study, or, or maybe the European, um, research testing community are a little bit more, uh, strict in what they’re asked to do. Um, and so, uh, and, and it was particularly in one arm of the trial where they’d lowered that cutoff to three, which was in the Rotterdam study.
Uh, in the other parts of this trial, they had the cutoff at four and didn’t show quite as much benefit as when you lower that cutoff to three. And so that European study showed, well, it showed a, a 21% reduction in prostate cancer-caused mortality, not all mortality, just prostate cancer-centered mortality, um, by being in the screening arm.
And, and I’ve said in my, you know, lectures, it’s, uh, 21%, that’s not much of a benefit. Like, 80% of people still died despite having PSA testing. [00:14:00] And, and the other aspect of the current guidelines are that we realize that in that European study, of the 80% of men that still died despite having PSA testing, most of them were detected on the first screening round.
So when they were first tested at age 55, they already had a cancer which was probably advanced. And so that’s why our guidelines and most guidelines around the world say you have to start before age 55. And that’s why the previous guidelines and the current guidelines say that we should at, start at age 50 In order to aid into that 80% risk of missing a cancer.
And if you’ve got a family history, you should act before age 50. Mm. And so, um, yeah, but that really all comes out of that European study, and it’s the basis of the previous guidelines and the new [00:15:00] guidelines.
Dr Travis Brown: So the age brackets that they’ve given us is 45 to 49, 50- Yeah … to 69, and then, uh, 70 plus. Yeah.
And so the, the levels are different though. So the 45 to 49 is one, uh, well, let’s just use, don’t worry about the units- Yeah … but just say above one. Yes. So who are the, is, is that just high-risk people that we’re recommending 45, or-
Professor Ken Sikaris: Yeah,
Dr Travis Brown: it’s
Professor Ken Sikaris: high risk- How does this work? … and the high risk are, well, first-degree relatives.
Now, it’s any brother, ’cause brothers are usually young, like similar age, 40 or 50. So if they’ve got prostate cancer at age 40 or 50, it was developing in the last 10 years. So you have to start 10 years earlier. And so, um, so the idea is you’ve got a brother, you have to start at age 45 normally. And then, uh, if you’ve got a father, well, he has to have had it at a young age, not at age 80, but age 65 and before, and that [00:16:00] implies that testing before age 50 might have caught his father’s cancers just like it would catch yours.
I mean, that’s the, the 45 to 49 group. So it’s, uh, or the other two, the other one, uh, risk factor there is, uh, BRCA1. So that we know that the BRCA1 gene causes an increased risk in breast cancer and prostate cancer, and it’s around a twofold increase in risk, just like that first-degree relative is. So once you hit that twofold risk, then you deserve to be screened earlier.
Uh, and so that’s the basis of the 45 to 49. That, yeah, once, uh, if you’ve got a first-degree relative, uh, and you’re being tested at age, uh, 50 and above, because of the age-related rise in PSA with age, the cutoff is still two in those men.
Dr Travis Brown: Right.
Professor Ken Sikaris: So bef- before age 49, it’s one, but if you’re catching a cancer at age 50 plus, the cutoff is two [00:17:00] One seems like such a low cutoff.
Steve Davis: Mm.
Professor Ken Sikaris: And, and one, in general terms, represents 50% of all 40-year-old men. But we’re not testing all 40-year-old men, we’re only change- testing the, you know, less than 5% of men who’ve got that high family history.
Dr Travis Brown: Yeah.
Professor Ken Sikaris: So, and, and there, as you would know, Travis, being histopathologist, the, um, as you would know, Travis, the, the young men have, often have a more aggressive cancer, Gleason 8, 9, 10 in the old scores.
And if those men have a PSA of 3, it’s odds on that it’s already out of the gland. So you have to detect it far earlier than a PSA level of 3. And, and we sort of always felt that 2 might be too close, and so they’ve, they’ve decided to shift that cutoff to 1 in the 45 to 49-year-old to catch, you know, the most tragic of prostate cancer, [00:18:00] which is men in their 40s and 50s having prostate cancer with a Gleason 8 and 9, 10.
They, that’s a lot of lives and, you know, a lot of life years saved- Mm … if you catch those men. Mm. So that, that’s a significant change in the guidelines, uh, uh, that, that young group. Yeah, 50 to 69 is exactly the s- as it was. If you’re above 3, confirm and, and, um, without the Free to Total. And then, uh, age 70 above, there are some subtleties there.
In the past, it was like if you’re age, over age 70 and you’re likely to live for seven years, keep testing. And, and, uh, I have to admit, uh, people used to equate age 70 as the point at which you’re li- likely to live for seven years, and that’s not true. The average, if you looked at an average survival of seven years, that would correlate to an age of 78 in Australians So, so in a, uh, you would expect any 70-year-old man in [00:19:00] Australia to live for at least seven years.
So it shouldn’t be a, an, an argument. Once they get to 78, then you’ve got that question of are they going to live for seven years and benefit from the screening? So, um, so that’s how w- we left it in the past, but now we’ve got some refinements to that. So what, what, what we say is that, uh, bec- PSA rises with age.
And so we say, if once you’re age 70 and you’re going to live for, um, w- likely to live for more than seven years, if your PSA is above 5.5, you deserve screening. You, you deserve to go on. If it’s, if it’s one or two and you’ve got the, you know, you’ve got the cancer at age 70 plus, it’s not likely to be aggressive, and so it’s not likely to kill you in your lifetime.
So it’s not worth following up those lower levels once above 5.5. And, and the other thing that they’ve done, because to a degree, our guidelines haven’t been reassuring enough. So, like, let’s say [00:20:00] for a man who’s 70 and his PSA is two or three, is there any value in him being tested anymore? And so the guidelines actually say if you’re age 70 and above and you’re below f- 5.5, it’s perfectly okay to stop testing.
And that would be very reassuring for those men, rather than for the next seven-plus years of their life having to come back and worry that they might have developed a prostate cancer. It’s like, no, i- I mean, the chances are they might have developed prostate cancer the longer they live, but they’re never gonna die of it.
Steve Davis: I’m, I’m looking for where the reassurance comes from as the person- … who is the patient- Yes … because we really have to trust the guidelines and trust- Yeah … maths.
Professor Ken Sikaris: Yes. That, well, and it’s, and you know, the PCF, Prostate Cancer Foundation Australia, are developing, you know, patient information brochures so that that information will be available to people.
They pr- they’ve [00:21:00] got websites so that they can explain things in lay language as well. So all of that’s, uh, largely being developed. So, um, um, I, I agree with you, Steve. And, you know, the reality is for GPs, they don’t really have a lot of time in the rushed consult environment of the modern world to explain these things in detail.
And, and there’s also the issue about- You know, men, m- men, maybe men in particular, but patients in general don’t absorb the information said during a rush consult. Yeah. They have to take it away and think about it and absorb it. So it’s a good point, Steve.
Dr Travis Brown: So are they still recommending the repeat test one to three months later?
Professor Ken Sikaris: Yes. Yeah, so that’s, that’s still there, the … Because men with benign prostatic hypertrophy do have what, you know, perturbations in their PSA, transient perturbations. Or in nom- normally it’s sort of like a subclinical [00:22:00] prostatitis due to the obstruction of the gland. And so, uh, so 30% of men with a PSA above three will test well below three on a repeat test in one to three months.
And so you avoid the cost of MRI in all those men and the risks of a false positive and everything. So, so that’s still there. We need to confirm that PSA rise. It’s much more to do with that natural perturbation of BPH than issues of ejaculation pushing up PSA or bike riding or horse riding and so on.
That’s not, that’s not the major reason we’re trying to improve the specificity of the test.
Dr Travis Brown: Will pathology tests or pathology labs still give free PSA? Because this is going to be a bit of a challenge between Medicare guideline, what’s, what’s rebatable for Medicare and what is
Professor Ken Sikaris: in the guidelines. It, it’ll take a lot of education.
Now, um, the way Medicare guidelines work, uh, from a regulatory level [00:23:00] is that the industry and the prof- you know, the clinical profession needs three months to prepare themselves for any change in guidelines. That’s actually in law. The only way the minister can avoid that is if it’s of such an important, you know, national significance, and he’s got a special instrument that he can rush through Medicare changes like they did in COVID and things.
So, so really we’ve, we’re, now, and that, uh, most of the changes tend to occur 1st of November, 1st of May, less sort of six months. And so we, we’re in the three-month window for first. It’s not gonna happen on 1st of November. So even though these are the new guidelines, and we’d probably encourage, um, doctors to think about applying them now rather than the old guidelines, the Medicare schedule probably won’t change, I would guess, until 1st of May next year, which gives us plenty of time to educate GPs, thank you very much, and as well as, um, through the College of Pathologists, [00:24:00] uh, and, and others, educate laboratories and patients going to the collection centers about, uh, the changes.
But I think that free-to-total ratio has been around for 30 years. It’s gonna be hard to just switch it off at the tap. And so patients will be, uh, asking for it, and depending on how the Medicare schedule’s structured, uh, it may not be rebatable at all, in which case, uh, it w- it’d probably be available as an out-of-pocket charge, um You know, most of those routine out-of-pocket tests are about $50 a test at a time.
Uh, that’s what I would predict, but, um, there’s still a bit of water under the bridge to know exactly where that lands.
Steve Davis: Ken, as someone who’s in a long-term relationship with his GP, and we’re on a first name basis too, I, I hasten to add, I’m curious to know whether digital rectal exam, uh, will still play a role in [00:25:00] screening patients for prostate cancer-
Professor Ken Sikaris: Um, I don’t want to say it’s the patient’s choice or you know what I’m saying.
No, the, the, in the, in the study, they found that digital rectal examination by non-specialists, now those studies were often residents in hospitals and rather than primary, uh, GPs and so on. It didn’t add any value. It had as many false positives as false negatives. So it, it added noise to the system. So, and the, the way that I interpret that is that when you’ve got an inexperienced finger You don’t really, n- you’re not really adding a lot of predictive power there.
And, and well, physical examination has changed very much in the 30 or 40 years that I’ve been prac- We had more time for physical examination back then, and now doctors don’t do as many rectal examination as part of the routine-
Steve Davis: Hmm …
Professor Ken Sikaris: clinical review. And so they don’t have that same [00:26:00] memory. So, um, that- Oh, I do.
Steve Davis: I remember it.
Professor Ken Sikaris: Yes. So the, the, um, whereas u- with urologists, of course them, their fingers are, you know, special. They know, they can detect things. So we’re certainly not saying things like urologists shouldn’t do rectally. They, it’s incredibly powerful for them to have that information. And, and the other aspect to, um, clinical examination is that, you know, a significant proportion of, of colon cancer is palpable rectally.
And so, you know, if patients have any risk of rectal, uh, cancer, they sh- they should have a rectal examination. So we’re not saying rectal examination disappears from primary care. We’re just saying it doesn’t add anything to the, to the screening for prostate cancer.
Dr Travis Brown: Now, the prostate cancer guidelines talk about the multiparametric [00:27:00] MRI, which is something I’ve never come across.
Right. It starts talking about things like PI-RADS, which I’m not even sure if I’m saying that correctly or not.
Professor Ken Sikaris: That’s right.
Dr Travis Brown: Okay. So with these called PI- What, what are these, what, what do GPs do with this? When does, when does this fit into, to the guidelines?
Professor Ken Sikaris: If a patient’s got a confirmed PSA above three, according to the guidelines, they’re entitled in the current Medicare schedule, in the current Medicare schedule it’s at the fee-for-total ratio, but that’ll disappear in the new guidelines now that it’s been endorsed by the NH and MRC and so on.
So if you’re confirmed above three, then the GP can refer you to a urologist who orders the multiparametric MRI. Now, I’ve spoken to dozens of GPs who say, “Well, why do, why can’t we order the, the MR- the multiparametric MRI?” And that’s certainly something that needs to be considered by Medicare when they [00:28:00] say who, ’cause the guidelines say you need an MRI- And the current convention is the urologist orders the MRI, but it should be considered by the Medicare committees whether GPs should be able to order that MRI.
And I, I, I’ve got a lot of sympathy for that, particularly because it’s often difficult to organize MRIs. Um, well, organize both a urology visit and an MRI, whereas it’s– it might be a lot simpler just to– for the GP to organize the MRI and refers them to the urologist with the MRI. We expect that this might increase slightly the number of MRIs that needs to be done, certainly if we im-improve the efficiency by having primary care referrals.
But one of the concepts that we’ve brought up is that, uh, I know this multiparametric MRI is, um, it’s beyond me. I’m not a ur– a, a radiologist or a urologist, so… But, but the way that they look at the different sort of contrasts and [00:29:00] frequencies in the MRI, they can look at three different phases of the MRI to locate what sort of cancer.
That’s why it’s called tri-parametric MRI. But in Australia, we’re sort of world leaders in, um, MRI because we’ve had these screening guidelines for so long. And our ur-urological, um, you know, specialists have developed a bi-parametric MRI, which is a lot faster and just almost as, as effective at screening for it.
And so they’re expecting they’ll be able to cope with any increase in volume because they’ve got this alternative of a bi-parametric MRI, the more efficient, faster MRI. So, um Yeah. Well, I mean, we- th- that’s why I’m sort of glad that we need a few months to sort out, um, exactly how the, uh, industry’s going to respond to, um, what these guidelines im- imply in terms of Medicare rebates and referrals.
Dr Travis Brown: So the people who have, [00:30:00] uh, PI-RADS or fit into a category, are they the people that go on to biopsy, are they?
Professor Ken Sikaris: Yeah, I should, uh … Look, there’s a bit of a declaration here. It- I’ve been working in PSA for s- well, 1989 or something. I was one of the first people to measure PSA in Australia. Like, we brought the first kits into Australia.
I was working at the Repat Hospital in Heidelberg with all the, well, you know, we had so many World War I, we still had World War I veterans and World War II veterans there, and they, um, there was a lot of them with prostate cancer, and there wasn’t, other than, you know, TURPs and, you know, chips from TURPs, to picking up subclinical prostate cancer.
The only way we picked up prostate cancer was metastatic disease. It was, it was- Wow … and every ward had patients with metastatic disease, you know, obstruction and bone pain and everything. So there was a real pressure to do that, and my, my mentor actually said, you know, “Ken, go out and [00:31:00] get a PSA test ’cause this might be what we’ve been looking for.”
And I didn’t realize I’d be, I will say, burdened with the responsibility of being- … Australia’s expert on PSA for the next 40 years. But but, uh, e- but I didn’t have any skin in the game. And, uh, and a couple of years ago, uh, my PSA started climbing. I was, uh, early 60s, and my PSA was, um, around four. And so because I helped write the guidelines, I realized what I had to do, so I repeated it, it was confirmed.
And then I had an MRI, and it was PI-RADS at two or something. It was PI-RADS. It, so PI-RADS is, I think, a five-point scale, and one on two is sort of anything above four or five is really high risk. So it was PI-RADS two, and so it was like, we’ll monitor the PSA. And so I monitored the PSA and it went to, like, three, four, five, and we, we were sort of reassured by that.
And [00:32:00] then, of all people, I made the mistake of not testing my PSA for four years.
Steve Davis: Ken.
Professor Ken Sikaris: And the PSA came back at 9.5 And 9.5, at, at a PSA of 10 is like the 50/50 chance for a G- a Gleason 7 cancer to have escaped the gland. So I’d run it far too close, with virtually 50/50 chance I’d, I’d let it escape the gland.
And so then I had the py- the MRI again, and it was PI-RADS 4, and they, and they picked up a cancer which was, uh, 40%, uh, grade four and, uh, 80% grade four, 20% grade three, so pa- uh, a Gleason 7, but predominantly four. And I had a radical prostatectomy. And I’ve had a, a … A- after all of that , I’m, I’m a very lucky man because my PSA’s been undetectable for [00:33:00] virtually the last two years.
So, so my case study, I’ve, I do, uh, share this with a lot of GPs when I’m giving them a, you know, an update on PSA because my case study demonstrates some interesting points, like the two-year screening interval’s enough to catch things, like four years was almost enough to catch, but I wouldn’t recommend that.
Um, it happened over years. So, you know, with the garden grade variety cancers of Gleason 7 and so on, you’ve got years to sort out what’s happening before it starts heading to 10 and you’ve escaped the gland. But, you know, again, in the guidelines, the point that’s made is that if you’re age 45 with a family history and everything and you’ve got a Gleason 8 or 9, you haven’t got years.
You- it’s n- you, you … When you hit three, it might have escaped the gland, and that’s why, you know, we’ve changed the whole picture when it’s family history and high risk. We [00:34:00] wanna catch it well before three. Yeah, so I didn’t… So now I’ve got skin in the game, I, I sort of do- no longer feel completely objective about this issue of PSA testing and prostate cancer.
I feel like I’m biased and, um, I may well be, but, you know, good for me ’cause I got away with stuff.
Steve Davis: I would use the term authoritative is,
Professor Ken Sikaris: uh- Authoritative …
Steve Davis: is where you’re sit at the moment. Um, that’s probably the perfect time just to draw breath for a moment and return to talk about higher risk patients.
Thank you, Ken.
We continue our discussion now with Professor Ken Zekaris, and as I mentioned before, we’re going to focus now on higher-risk patients for prostate cancer screening. Ken, m- who are the patients that are considered higher risk?
Professor Ken Sikaris: [00:35:00] So we mentioned the first-degree relatives, so that’s about a twofold risk. Um, uh, and, and if it’s your father b- before age 65, uh, but any brother, the BRCA1, the genetic link.
There’s also, um, African populations who have a higher risk. So, um, and, and there it’s, uh, we know, we know how capable Africans are in sport. They have higher testosterone levels, and that’s thought to be sort of behind this increased risk in, uh, prostate cancer in those men. But there’s another aspect to those African men, which is, like, access to healthcare And so now they, they’ve dec- they’ve virtually decided that, um, Austra- indigenous Australians, they don’t have a, a physiologically higher risk of prostate cancer, but [00:36:00] their access to healthcare is so poor that they deserve special attention.
Like, they, you really should be trying harder in not only prostate cancer, but everything for those indigenous communities. So there are some clauses in the guideline to say that they’re a special population. They don’t call them high risk, but they are a special population who deserves more attention because they’ve sort of lacked, um, equivalent attention- Hmm
in the past, and they have higher risks. Um, we haven’t said that for all of rural Australia because it’s profound in the indigenous populations, but it is slightly true of all indigenous Australia. From the Victorian Registry for Prostate Cancer, we know that regional, um, men living in regional Victoria have significantly worse outcomes for prostate cancer than men living in the city.
And so, but that’s not, that’s sort of just something that, you know, GPs and s- should try harder rather than [00:37:00] labeling them at high-risk populations. So the high risk, you know, from a, a biological perspective, uh, family history, BRCA1, and the African, uh, populations.
Dr Travis Brown: So some of the genetic mutations come up. I see the, one of the ones is BRCA.
You’ve mentioned BRCA1, but it s- it also says BRCA2, uh, as, as high risk. So would you- Yeah … just put anyone that has genetic mutations into high risk
Professor Ken Sikaris: regardless? I, I, well, I would. There are sort of, uh, there are people that have y- sort of DNA profiling and they’ve got, you know, multiple alleles that all point together to a, you know, 1.8-fold risk.
It’s like there is a, there is a beauty in the Medicare schedule at the moment in terms of MRI, ’cause that’s the gateway to, um, biopsy and detection, that it’s not only men who have a PSA confirmed above three, it’s men who a urologist judge as being at high risk, [00:38:00] and that includes their, you know, their informed, uh, uh, digital rectal examination.
So, so, you know, it’s, it’s almost artificial in clinical care to say we only consider the PSA or we only consider the, you know. It’s really that whole profile. So if you’ve got a man who’s got, um- A cousin with prostate cancer who died at age 55 and, you know, they’ve got this multiple allele thing and there’s no, it’s hard to create guidelines around all those variations.
But the Medicare schedule, I’d be very surprised if it didn’t maintain it, say if a urologist judges it at high risk, they get an MRI. And so I think that those things all contribute to understanding a man’s risk.
Dr Travis Brown: So yeah, things like Lynch syndrome, hereditary breast and ovarian cancer, effectively I would probably end up just sending them to a urologist and say, ‘You sure?’
Professor Ken Sikaris: Yeah. I mean, I think that a lot of those things increase risk by 35 or 50% rather than 100%.
Dr Travis Brown: Yeah.
Professor Ken Sikaris: And so they are risk factors, but they’re, they haven’t [00:39:00] hit that threshold, which is effectively that first-degree threshold.
Dr Travis Brown: So people then, there’s also a term called active surveillance. Uh, and what is active surveillance?
Professor Ken Sikaris: Active surveillance is you know, I mentioned before, you know, my PSA was high, the pi- the MRI was okay. It didn’t look like I had prostate cancer. Well, you don’t just say, ‘Well, that’s the end. Don’t worry about it.’ You say, ‘Well, you know, we, our, our s- testing procedures aren’t perfect. We need to keep monitoring.’
And active surveillance would be, uh, usually under the, under a urologist, so you know, every year or two you’d see the urologist, he’d check the PSA, uh, do the r- rectal examination, order an MRI if things had changed. And so now, and you’re right to raise this, Travis, because Australia is the leader In active surveillance.
So in the past, there was this issue of [00:40:00] over-treatment. Anybody who had got labeled with prostate cancer, you know, off for a radical prostatectomy. And whereas the reality is, um, you know, depending on how a- aggressive it seems, like, say the PI-RADS score is borderline and the PSA’s not really, uh, high and rising, the, um, you can watch that patient because l- like, like I was saying with the garden variety Gleason 7 cancers, it’s not gonna do much.
It’s not gonna escape the gland in two years’ time. They can monitor every year or two. And, and in Australia, look, I’m not sure of the exact figures, but it wouldn’t be an understatement to say most men that are referred to urologists with a raised PSA and a suspicion of prostate cancer, but a PI-RADS, you know, that’s reassuring, um, they just go onto active surveillance.
And we, like I was saying, our, our proportion of men who go onto active surveillance rather than treatment is [00:41:00] higher than almost anywhere in the world. And that’s another reason why the guidelines, you know, got a good hold, because we’ve got proof that both our GP and our urology community are very responsible in the way they deal with, um, the tools that are available today.
Dr Travis Brown: Is there any gaps or omissions that you think we’ve sort of, we’ve missed on these guidelines yet? Or is there anything that you’re thinking about that we, that should be included?
Professor Ken Sikaris: No, I th- I, I think that, i- it’s a Medicare, that issue about GPs being able to refer to the MRI, I think that’s a, a, to me, that’s an important consideration bec- it sort of just helps the whole process.
Um, I, look, there’s one thing I j- briefly mentioned there, which was to do with the PSA rise. So now in the European study, they didn’t look at, technically they didn’t look at PSA rises. They didn’t calculate them. They didn’t use them as a, as a [00:42:00] decision tool. I p- I’m sad that they didn’t because, um, I think that it is a u- a very useful indicator.
It’s not something that’s a simple calculation, like has your PSA risen by one? There, there used to be a guideline, if your PSA’s risen by .85 in a year, the so-called PSA velocity, it’s a risk factor. But that was based on the days when the only men that, you know, got detected with prostate cancer had PSAs well above four.
So, you know, in a young man who’s got a PSA of, let’s say, one, which is now the… And you say, ‘Well, if it gets to 1.7 in a year, don’t worry about it.’ It’s like, ‘What do you mean don’t worry about it? It’s, it’s, that’s terrible.’ And so the proper way to interpret, um, PSA changes is by something called a PSA doubling time.
Steve Davis: Right.
Professor Ken Sikaris: And, and we, what we don’t have, and we will, never will have a, you know, a [00:43:00] controlled study which proves whether doubling time or velo- or velocity is, adds to the screening procedure. But it doesn’t mean you should ignore it. It should be like the rectal examination, the patient’s anxiety, their family history.
It’s something that you should take into account. And, and I certainly do, and I know a lot of urologists do as well. They calculate the doubling time. Um, the place that I, uh, suggest for most people, because it’s a logarithmic calculation, it’s not something you can do easily without a calculator or a slide rule.
Mm-hmm. Now I’m showing my age. But, uh, the, the, so the, um… But you can go to the, um, Memorial Sloan Kettering, which is a huge cancer institute in New York. They’ve got a website where you can plug in the values and calculate the doubling time, and it’ll tell you about the risk associated with the doubling time.
And, and in general terms, um, if your PSA’s doubling every five [00:44:00] years, well, that’s just benign prostatic hypertrophy If your PSA is doubling faster than every three years, you’re likely to have a cancer. If it’s doubling every year, you’ve got an aggressive cancer, like Gleason 9, 10 cancer. So, um, there’s a gray zone of if it’s between three and five years, y- what, you don’t have BPH and you don’t have cancer.
Well, that’s the, all those cancers that probably won’t affect you in your lifetime. So, so it, it is a guide for that, but unfortunately, because of the lack of evidence, I don’t think it, it credits being in a formal guideline. But in practical terms, I wouldn’t miss out on the opportunity of using that as part of the decision-making process.
And certainly patients get anxious when the PS- they see their PSAs rising, what are you gonna say? Well, sorry, we don’t know how to interpret that. No, we do know, it’s just not part [00:45:00] of the guidelines.
Dr Travis Brown: Now, these guidelines are gonna be reviewed in 2031. Is that, uh is that the normal sort of five, five-year time gu- timeline?
Professor Ken Sikaris: Oh, it’s supposed to be faster than that, but it takes, it probably takes five years to get the committee and the funding for all the committee. There’s so much work that goes into these guidelines. It’s not, it’s not just, you know, old boys around the table just making out. We’ve, there’s a team of epidemiologists and researchers that scour the guidelines, there’s statisticians and so on.
It costs, you know, to the credit of PCFA and the government which helped to sponsor them, it costs hundreds of thousands of dollars to redevelop the guidelines. And, and that’s putting aside all of the pro bono time from, you know, the, the, the best specialists the country has to offer for dozens of meetings over the year, over the few years that it takes.
So they’re, they’re incredibly, [00:46:00] um, re- resource demanding things, and so it’s not something that you just flippantly say, “Oh, let’s do another one,” you
Steve Davis: know? In between those major reviews, is there active monitoring?
Professor Ken Sikaris: That’s a really interesting thing, Steve, because, I mean, we’ve been skirting around this issue that p- prostate cancer screening is not an endorsed screening program in Australia.
PSA testing in the schedule is in, is government funded- But prostate cancer screening is not. It’s very confusing. It’s sort of, well, is it or isn’t it? It isn’t, technically. And that’s sort of a little bit of a barrier because most, uh, cancer screening programs have registries. And I’m not saying those registries work fantastically, the colorectal registry and other things.
Um, but they have registries which can inform the government about how these screening programs are going, whether they’re being effective and, and so on, [00:47:00] and what proportion of the population’s taking part of them and so on. So we don’t have that for prostate cancer, and we won’t have… We may not have.
But the Victorian registry does exist, and so people, researchers, there’s plenty of people who are interested in prostate cancer and research, they do have access to some databases which will tell them how that’s going. And, and one of those databases w- you know, did show this problem of the men under age 40 that, you know, they, they were still getting aggressive cancers and dying.
There weren’t many of them, but they, we weren’t helping them. Yeah. And so, um, yeah, so it is really, uh, we don’t have a formal way of reviewing how this PSA testing process goes, but we do have, uh, various databases that we can look at t- to, to see, uh, whether they’re effective or not.
Steve Davis: Are there any final bits of advice you might have or some guidelines for doctors about prostate cancer [00:48:00] screening and PSA testing?
Professor Ken Sikaris: Steve, there’s probably something that I, I’m negligent in not emphasizing. The 2016 guidelines effectively said, and this was transferred to the RACGP Red Book, it effectively said, if the patient brings up the issue of prostate cancer testing, then you give them the for and against, and this is the protocol.
The new guidelines say that GPs should br- should initiate the discussion for men, particularly in that 50 to 69 window. So now that’s a, that’s a huge change at a medico-legal level. So, and, and, and to be honest, because of the existence of MRI and, you know, and active surveillance and everything, GPs are much more confident about, you know- discussing these issues th- than they were ten years ago.
And so it’s been a natural progression to sort of say, “Okay, [00:49:00] well, now we have to draw the line. We have to say that this is something that every GP should be able to address and manage with.” And this is a significant health issue for men between the age of 50 to 69, and so one that should be initiated as part of a health check for that man.
So that’s a significant change. And, and remembering these guidelines have been endorsed by the College of General Practice, and so the College of General Practice agree that GPs should initiate the discussion in men in the, in the right age group.
Steve Davis: And just before I do say goodbye, it was a shock. We’re just digesting the fact that you let your screening lapse four years, Ken.
Uh, we don’t wanna dwell on it, but do you understand why? Is, was it just life got in the way? Because this will be a common story for patients.
Professor Ken Sikaris: Yeah, look, it may be, you know, a l- my knowledge, I was looking at my PSA doubling time, and then my PSA had gone from four to five to five, and it was like a, the, the [00:50:00] doubling time was in that three to four year range, and I thought, well, you know.
And then, but when it hit nine point five and, and the doubling time was clearly under three years, then, um- Look, I will say one thing. I, the reason I got it was I wasn’t 100% sure whether I’d save my life by having the radical prostatectomy. I wasn’t, because I’m not sure how long I’m gonna live, I’m not sure how…
But I, I was 100% sure that I’d saved myself the risk of metastatic disease and the risk of hormonal therapy and, and all of those, or radiation and so on. And so, um, and that’s, and that’s where that decision-making’s important. So some men may value their sexual potency much more than their life. So every man’s different.
And so from my perspective, um, you know, initially I felt like, well, if this is a benign [00:51:00] cancer, you know, I’d be able to manage it, but if it’s an aggressive cancer, I need h- more therapy to prevent metastatic disease, and the impact that would have on my family, you know, like seeing that, you know, that it’s, it’s, uh…
But I think that the thing is with this is the more information, the more power you have in making the decision, and I lapsed with that information by not having it at least every two years. I live in a laboratory, for God’s sake. I could’ve had my PSA done every month if I wanted to. So there’s no excuses, but I was falsely reassured by that, and I hadn’t, I probably didn’t visit the urologist as frequently as he would’ve wanted for the active surveillance.
So yeah, life getting in the way maybe, Steve.
Steve Davis: Yeah. Well, look, thank you for the honesty on that. I think that probably lands all the learning so much more than our higher level conversation. But Professor Ken Tsakiris, thank you very much for returning to This Medical Life.[00:52:00]
This Medical Life is recorded in the Talked About Marketing Studios in Adelaide. For show notes and more information about the podcast, visit thismedicalife.com.au. You can contact the hosts on social media. Dr. Travis Brown can be found on X. His username is @drtravisbrown, that’s D-R Travis Brown. And Steve Davis can be found on LinkedIn.
Go to linkedin.com/in/therealstevedavis. This has been a Pathnotes Proprietary Limited production