While it is known that national PSA testing rates have decreased in Australia since 2007, it is not known whether these trends are consistent by broad geographical areas, nor whether previously reported area-specific differences have remained in more recent time periods.
Population-based cohort study of Australian men (n = 2793,882) aged 50–69 who received at least one PSA test (Medicare Benefit Schedule item number 66655) during 2002–2018. Outcome measures included age-standardised participation rate, annual percentage change using JoinPoint regression and indirectly standardised participation rate ratio using multivariable Poisson regression.
During 2005–09, two thirds (68%) of Australian men aged 50–69 had at least one PSA test, reducing to about half (48%) during 2014–18. In both periods, testing rates were highest among men living in major cities, men aged 50–59 years, and among men living in the most advantaged areas. Nationally, the Australian PSA testing rate increased by 9.2% per year between 2002 and 2007, but then decreased by 5.0% per year to 2018. This pattern was generally consistent across States and Territories, and socio-economic areas, however the magnitude of the trends was less pronounced in remote and very remote areas.
The decreasing trends are consistent with a greater awareness of the current guidelines for clinical practice in Australia, which recommend a PSA test be done only with the informed consent of individual men who understand the potential benefits and risks. However, given there remain substantial geographical disparities in prostate cancer incidence and survival in Australia, along with the equivocal evidence for any benefit from PSA screening, there remains a need for more effective diagnostic strategies for prostate cancer to be implemented consistently regardless of where men live.
- • Analysis of individual-level Medicare data in Australia.
- • PSA screening tests have declined since 2007.
- • Assessed trends by states/territories, remoteness and area disadvantage.
- • Trends by geographical area were consistent with the national trends.
- • National factors more likely to influence trends than local factors.
Prostate-specific antigen (PSA) testing in asymptomatic men can instigate an early diagnosis of prostate cancer, potentially avoiding higher risk disease and enabling the management to be more effective. While it remains the most commonly used test for prostate cancer screening or monitoring after a prostate cancer diagnosis or its treatment, its use as a screening test for prostate cancer is widely debated due to its high sensitivity and a low specificity , its inability to distinguish between cancers and non-cancer conditions, and the known harms associated with overdiagnosis and over-treatment of screen detected cancers . Increased rates of PSA testing are typically associated with increases in prostate cancer diagnoses and higher observed cause specific survival .
While population-based screening for prostate cancer is not endorsed internationally nor implemented as policy in any country in the world, during 2005–2009 52% of Australian men aged 40 years and over had at least one Medicare-funded PSA “screening” test . Medicare reimburses four categories of PSA tests (66655, 66656, 66659 and 66660) and for the purposes of this paper we refer to item 66655 as de-facto “screening” tests (henceforth referred to as PSA screening tests), as it relates to tests undertaken on asymptomatic men. In 2016, the Prostate Cancer Foundation of Australia and Cancer Council Australia released national evidence-based guidelines that did not recommend a population-based prostate screening program, and instead advised informed individual decision-making regarding PSA testing. The guidelines state that men aged 50–69 years who make an informed decision to have a PSA test be offered biennial PSA testing. These recommendations are generally consistent with similar USA and Canadian recommendations .
In Australia, PSA screening rates have been consistently lower among men living in less accessible regional and remote areas of Australia versus the rest of the country , and lower in socioeconomically disadvantaged populations , however these estimates relate to the period of highest PSA testing rates more than ten years ago. While modelled rates have decreased nationally since around 2007 it is not known whether these trends are consistent across geographical areas, and whether the geographical disparities reported previously have persisted over time.
The aim of this study is to describe Medicare-funded PSA screening test patterns and trends by State and Territory, remoteness of residence and socio-economic status. This information may be used to guide policy makers about temporal changes in PSA testing and its implementation, and thus inform the development of recommendations or future revisions of the Australian PSA testing guidelines.