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GPs go forth

GPs should not screen patients over 70 for prostate cancer, researchers say

GPs should not carry out PSA screening on men aged 70 and over as the harms outweigh any potential benefits, new guidelines from the US have said. 

The guidance, published in the Annals of Internal Medicine by the US Preventive Services Task Force (USPSTF) goes against Public Health England advice to offer the test to ‘any well man aged 50 and over who requests it’.

PHE said the UK National Screening Committee will review these new findings as part of its next recommendations update.

In drawing up the guidance, researchers carried out a systematic review of trials and studies relating to PSA screening in men without symptoms of prostate cancer.

The research concluded that asymptomatic men aged 55 to 69 years should only be screened if they request it, regardless of whether they have an increased risk for prostate cancer death due to race, ethnicity, or a family history of prostate cancer.

It added that PSA screening should not be carried out in men aged 70 years and over.

The researchers wrote: ‘Men (55 to 69 years of age) should not be screened unless they express a preference for it after an opportunity to discuss potential benefits and risks of screening and to incorporate their values and preferences in the decision.

‘In men 70 years of age and over, the USPSTF recommended against PSA screening for prostate cancer.’

The guidelines added that for men aged 70 and over, the recommendation was ‘based on moderate certainty that potential benefits do not outweigh expected harms’.

PHE’s current prostate cancer risk management guidance for asymptomatic men says: ‘The PSA test is available free to any well man aged 50 and over who requests it.’

But PHE’s UK director of programmes Professor Anne Mackie said: ‘The UK’s independent expert screening committee will review the findings of this new international guidance.

‘The committee is currently planning its next update and will consider the results of this research.’

BMA GP Committee clinical and prescribing policy lead Dr Andrew Green told Pulse: ‘It is interesting to note that even in the screening-hungry States the appetite for this test is decreasing.

‘The fact is that PSA testing for men without increased risk fails all the criteria for a valid screening test, producing no increase in survival at great risk of harm through over-diagnosis.’

Researchers previously found that while doing PSA tests on men without symptoms detects disease unlikely to cause harm, it often misses aggressive and lethal prostate cancers.

However, following this study, NICE told Pulse that it has no plans to review its recommendations on digital rectal examinations for prostate cancer.

Readers' comments (5)

  • Ivan Benett

    This is the important message: Public Health England advice to offer the test to ‘any well man aged 50 and over who requests it’.
    Although PSA does NOT fit criteria for screening populations, it can estimate the risk of prostate cancer for individuals, At least then they can decide how to proceed. These possibilities should be discussed before the test is taken, but come into sharp focus if the level is raised.
    For example if level persistently 4 then there's a 30% chance of cancer (and a 70% chance of not cancer).
    As for 70s, I would still test if symptomatic. You'd look a bit silly if you missed it
    "BMA GP Committee clinical and prescribing policy lead Dr Andrew Green told Pulse: ‘It is interesting to note that even in the screening-hungry States the appetite for this test is decreasing." Indeed, but PSA is not a screening test. Although the number of tests has reduced, it is still a common request in USA, as it should be here for people with a family history or of African origin.

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  • Unless I'm mistaken, LUTS are a symptom potentially suggestive of prostate cancer. (A pretty rubbish symptom, poor PPV, sensitivity, specificity etc, the whole lot).

    What 70+ year old doesn't have LUTS on direct questioning?

    So we are rarely "screening", but investigating.

    (There's also a problem with using the word "screening", to mean individual risk assessment).

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  • AlanAlmond

    What would an AI bot driven app do with this little gem?

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  • This area does require careful consideration and I do worry about whether the current systems of NHS Screening are fit for purpose to undertake such a complex review compared to, for example, NICE.

    There are certainly some inconsistencies between the USPSTF advice on colorectal cancer screening and age and their revised advice on prostate screening and age which needs looking into. In both cases the evidence for the benefits of screening at older ages is limited.

    The PLCO and ERSPC trials included men 74 years and younger; men older than 70 years were not in the core age group (55-69 years) in the ERSPC trial. The CAP trial did not enrol men older than 69 years.

    The USPSTF recommend that for men aged 55 to 69 years, the decision to undergo periodic prostate-specific antigen (PSA)–based screening for prostate cancer should be an individual one. I would suggest that this approach should continue be offered to those over the age of 70 with at least a 10-15 year life expectancy.


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  • Vinci Ho

    The conundrum question here is , in fact , how to pick up the actively progressive and aggressive prostate cancer (arguably other cancers), in both investigative and screening proceedings , simply because aggressive cancers can be occult, asymptomatic and clandestine . Then the philosophical question is how many otherwise fine patients have to be ‘sacrificed’ to achieve this objective?
    The limitation is indeed the sensitivity and specificity of the actual test, PSA in this case , and hence , following closely to that is the so called ‘fitness of purpose’ of the screening system.
    In countries where medicine is mainly driven by private funds, e.g. China , India and many Far East countries , this is not even an issue . Everyone will just go for it , you pay more and get more tests done.
    ‘Going too far is as incomplete as not going far enough ‘ (過猶不及)as Confuscius taught his students in the book of Analects. The article last month in BMJ on over-diagnosis in primary care is inspiring and introspective:

    Overdiagnosis in primary care: framing the problem and finding solutions
    BMJ 2018; 362 doi: (Published 14 August 2018)

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