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Screening and early diagnosis: Prostate cancer

Dr Alison Round and Professor David Weller discuss the benefits of prostate cancer screening and PSA tests

Dr Alison Round and Professor David Weller discuss the benefits of prostate cancer screening and PSA tests

The natural history of prostate cancer is not well understood, and can vary greatly from aggressive invasive disease to very indolent tumours that do not contribute to morbidity and mortality.

By the age of 80, 60-70 per cent of men will have some cancer cells in their prostate, yet only 4 per cent will die of prostate cancer.

The number of deaths from prostate cancer in the UK has remained relatively stable over the past 15 years despite a doubling in incidence. In broad terms, a 50-year-old male has, over a lifetime, a 10 per cent chance of being diagnosed with prostate cancer, with a 4 per cent chance of death from it.

The introduction of prostate cancer screening would increase the chance of a lifetime diagnosis to about 20 per cent, but there is no good evidence that there would be any reduction in the risk of death. At present, about 8 per cent of cancers in the UK are diagnosed as a result of asymptomatic testing; in countries where prostate specific antigen (PSA) testing is much more widespread, about 30-75 per cent of cancers are identified through this route.

The increase in incidence is largely attributable to the increase in PSA testing, which is being used in some places as a screening tool even though no screening programme is in place in the UK.

Instead, there is a prostate cancer risk management programme, which indicates that PSA testing can be performed, provided the man fully understands the lack of good-quality evidence for the risks and benefits of testing.

Within this programme, there should be a standardised pathway for men whose test result is above the threshold. The sensitivity of PSA (using a threshold level of 4ng/ml) is about 70 per cent, so an elevated PSA is not diagnostic of cancer.

An ultrasound-guided prostate biopsy is required to establish the diagnosis. This may miss the tumour and is itself only about 80 per cent sensitive. A large randomised study of prostate screening and treatment (the CAP and ProtecT trials) is under way in the UK.

Risk factors and advances

There is a genetic component to prostate cancer. The risk rises if relatives are diagnosed at an early age; with three affected relatives, the risk is raised seven to 10 times. African-American men have about twice the risk of white men. However, even with a strong genetic risk, active case finding is not recommended in the UK. There is no fundamental link with BPH, although men with BPH often have a PSA test, revealing a cancer.

  • Alison Round is a GP in Tiverton, DevonDavid Weller is a GP in Edinburgh and professor of general practice at the University of Edinburgh

This article is an extract from Cancer Diagnosis in Primary Care, edited by W Hamilton and T J Peters, ISBN 978-0-443-10367-4, published by Churchill Livingstone Elsevier, price £19.99. To order a copy visit or phone 01865 474000.

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