My dad is sixty-three. He's had his cholesterol checked — I wrote about that in Article #5. His HbA1c, Article #8. His cardiovascular risk, Article #10. By this point, his GP knows him well. She monitors his metabolic picture closely.

At his most recent visit, she brought up PSA.

He told me about it over the phone. Not anxious, more confused. "She said it's my choice. She said there are benefits and risks. She said some doctors think it's important and some think it causes more harm than good. Then she asked what I wanted to do."

He paused. "Mate, I don't know what I want to do. I don't even know what PSA stands for."

Prostate-specific antigen. It's a protein produced by the prostate gland. When PSA is elevated in the blood, it can indicate prostate cancer, but it can also indicate a dozen other things that aren't cancer. That ambiguity is the entire reason this test is the most debated screening tool in Australian medicine.

Prostate cancer is the most commonly diagnosed cancer in Australian men. Roughly 1 in 6 men will be diagnosed during their lifetime. It's also the second most common cause of cancer death in men, after lung cancer. These are serious numbers. And yet, unlike breast cancer screening (which has a national program) or bowel cancer screening (which has a national program), prostate cancer screening has no organised national program in Australia. The decision is left to individual men and their GPs.

This article explains why. What PSA measures, what it misses, what the evidence says about screening, what the Australian guidelines recommend, and how to have the conversation with your GP that my dad wasn't sure how to start.

A note before we get into it

What PSA is, and what it isn't

PSA is a protein produced by both normal and cancerous prostate tissue. A blood test measures the amount of PSA circulating in your bloodstream.

What it is: A marker of prostate activity. Elevated PSA means the prostate is producing more of this protein than typical, which can happen for multiple reasons.

What it isn't: A cancer-specific test. Elevated PSA does not mean you have prostate cancer. Normal PSA does not guarantee you don't.

Causes of elevated PSA that aren't cancer:

Benign prostatic hyperplasia (BPH), or prostate enlargement, which is extremely common in older men. Prostatitis (prostate inflammation or infection). Urinary tract infection. Recent ejaculation, which can transiently elevate PSA. Recent vigorous exercise, particularly cycling. Recent prostate manipulation (examination, biopsy). Age, since PSA naturally rises as the prostate grows.

This is the fundamental challenge. PSA has high sensitivity (it catches most prostate cancers) but low specificity (it flags many things that aren't cancer). That means PSA screening produces a significant number of false positives: elevated results that lead to further investigation, including biopsy, in men who don't have cancer.

The controversy: why PSA screening divides medicine

The debate over PSA screening is one of the most polarised in medicine. Here's why, presented as honestly as I can.

The case for screening: The European Randomised Study of Screening for Prostate Cancer (ERSPC), the largest and most influential trial, found that PSA-based screening reduced prostate cancer-specific mortality by approximately 20% over 16 years. For men who are diagnosed with aggressive prostate cancer, early detection through PSA can be life-saving. Without screening, some men would present with advanced, incurable disease that could have been caught and treated earlier.

The case against population screening: For every life saved, PSA screening identifies many cancers that would never have caused harm during the man's lifetime. Overdiagnosis estimates range from 23% to 42% of all screening-detected cancers. These men undergo the psychological burden of a cancer diagnosis, and often invasive treatment (surgery, radiation) with significant side effects — erectile dysfunction, urinary incontinence — for a cancer that would never have threatened their life.

The numbers for context: Modelling based on Australian data suggests that for every 1,000 men screened with PSA every two years from age 50 to 69, approximately 1–2 prostate cancer deaths are prevented over 16 years, while roughly 5–6 men are overdiagnosed and potentially overtreated.

What's changed recently: The overtreatment concern has been partially addressed by the increasing use of active surveillance for low-grade prostate cancer (monitoring rather than treating), multiparametric MRI (which can identify clinically significant cancers before biopsy), and transperineal biopsy (safer than the older transrectal approach). These advances mean that an elevated PSA in 2026 leads to a much more nuanced pathway than it did a decade ago.

The Australian guidelines: what's actually recommended

Australia released draft 2025 Clinical Practice Guidelines for the Early Detection of Prostate Cancer, making it the first country in the world to publish formal clinical guidelines on this topic (replacing the narrower 2016 PSA Testing guidelines).

The core recommendation: PSA testing should be offered to men aged 50–69 as part of an informed, shared decision-making process with their GP. Testing every two years is the recommended interval for those who choose to test.

Higher risk groups (earlier testing from age 40):

Aboriginal and Torres Strait Islander men. Men of sub-Saharan African descent. Men with BRCA2 gene mutations. Men with a family history of prostate cancer (father diagnosed before 65, brother diagnosed, or two or more second-degree relatives who died of prostate cancer).

Men aged 40–49 without risk factors: May choose to test, but the evidence of benefit is more limited. Shared decision-making applies.

Men over 70: Testing may be discontinued in healthy men with PSA below 1.5 µg/L, as they are unlikely to benefit from further screening. Continuation beyond 70 should be individualised.

The critical principle: No man should be tested without understanding what the test can and can't tell him, and what the potential consequences of an abnormal result are. This is informed consent, and it's the foundation of the guidelines.

Who should consider testing

Men aged 50–69. This is the evidence-based age range. The decision to test should be made in consultation with your GP after discussing the benefits (potential early detection of aggressive cancer) and harms (false positives, overdiagnosis, psychological impact, potential overtreatment).

Men aged 40+ with risk factors. Family history, Aboriginal and Torres Strait Islander heritage, sub-Saharan African descent, or known BRCA2 mutations. These groups have higher prostate cancer risk and may benefit from earlier screening.

Men with urinary symptoms. If you have lower urinary tract symptoms (difficulty starting or stopping urination, weak stream, frequent urination, nocturia), PSA may be part of the investigation. But this is symptom-driven testing, not screening.

Men who have already started testing. If you have a baseline PSA, your GP can track changes over time. A rising PSA (velocity) may be more informative than a single elevated reading.

What the numbers mean

PSA below 1.0 µg/L (age 50–69): Low risk. Repeat in 2 years.

PSA 1.0–3.0 µg/L: Normal for most men, particularly with age. Repeat in 2 years or as advised.

PSA 3.0–5.5 µg/L: Warrants discussion. May reflect benign causes, but further investigation may be considered, particularly if rising over time.

PSA above 5.5 µg/L: Further investigation typically recommended (MRI, possible biopsy). Does not mean cancer is present, but the probability is higher.

These thresholds are guidelines, not rules. PSA interpretation depends on age, prostate size, rate of change, family history, and clinical context. Your GP integrates all of this. A number alone doesn't determine the path.

Free PSA ratio: Some clinicians use the ratio of free PSA to total PSA to help differentiate between benign and malignant causes. A lower free-to-total PSA ratio may suggest a higher probability of cancer. It adds nuance to borderline results.

What happens after an elevated PSA

The pathway has changed significantly in recent years. An elevated PSA no longer automatically leads to biopsy.

Step 1: Repeat PSA. A single elevated reading is confirmed with a repeat test, usually 4–6 weeks later. Transient causes (infection, recent ejaculation, exercise) may resolve.

Step 2: Multiparametric MRI. This is now the standard next step for a persistently elevated PSA. MRI can identify suspicious lesions in the prostate and grade their clinical significance. If MRI is normal, biopsy may not be needed.

Step 3: Targeted biopsy (if indicated). If MRI identifies a suspicious area, a targeted biopsy (transperineal approach, guided by MRI/ultrasound fusion) provides tissue for pathological assessment. This is more accurate and safer than the older untargeted transrectal approach.

Step 4: Management decision. If cancer is confirmed, the grade (Gleason score / ISUP grade group) determines the approach. Low-grade cancer (ISUP 1) is increasingly managed with active surveillance, meaning monitoring without immediate treatment. Higher-grade cancers may require surgery, radiation, or other treatments.

This pathway means that an elevated PSA in 2026 does not automatically mean invasive procedures. The system has become more discriminating, which reduces (but doesn't eliminate) the overdiagnosis and overtreatment concerns.

The conversation every man should have

My dad's confusion ("she said it's my choice") is actually the system working correctly. The guidelines explicitly require shared decision-making. Your GP can't just order the test without discussing it. And you shouldn't request it without understanding the implications.

Here's what to discuss:

Your risk factors. Family history, ethnicity, age, symptoms. These determine whether you're in a standard or elevated risk category.

What PSA can and can't tell you. It's a screening tool with meaningful limitations. It's not a cancer diagnosis.

What happens if PSA is elevated. The pathway (repeat PSA, then MRI, then possible biopsy) and what each step involves.

The possibility of overdiagnosis. Some cancers detected through screening would never have caused harm. Understanding this is part of informed consent.

Your personal values. Some men want to know their PSA and accept the implications. Others prefer not to screen and accept the small possibility of missing an early cancer. Both positions are valid. The guidelines support either choice.

My dad, after thinking about it, decided to test. His PSA came back at 1.2 µg/L, well within normal range. He'll retest in two years. He told me: "I'm glad I know. Even though it was normal. Now I've got a baseline."

How to prepare

Tests to consider through Bloody Good

Broader men's health context:

Testosterone Free/Total + SHBG. Hormonal health, relevant for men discussing prostate health with their GP, as testosterone and prostate health are linked.

Full Blood Count (FBC). Baseline health marker.

Kidney Function (eGFR). Particularly relevant for men over 50.

If you want the full picture in one go:

The Bloody Good Test covers 100 biomarkers across every major health domain. For men over 45, pairing it with a standalone PSA test provides the most thorough annual health baseline available.

For age-specific testing guidance, see our blood tests by age guide.

What this article is really about

This article is about a conversation. Not about a test.

The test takes five minutes. The conversation, understanding what PSA means, what it can and can't tell you, what happens if it's elevated, and what your options are, is what matters.

Most Australian men never have this conversation. They either get tested without understanding the implications, or they avoid the topic entirely. The draft 2025 guidelines are trying to change that. To move prostate cancer screening from "just do the test" or "just don't worry about it" to an informed, shared decision between a man and his GP.

My dad had the conversation. He made his choice. He's got a baseline. And now, when he retests in two years, his GP will have a trend, not just a number.

That's what proactive testing looks like. Not panic. Not avoidance. Just information, discussed openly, and a decision made with your eyes open.

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Explore more biomarkers

If you want to go deeper into PSA or any of the markers covered here, the Bloody Good biomarker directory has detailed pages on what each test measures and how to think about your results in general terms.

Browse the Bloody Good Biomarker Directory