PSA debate reignites ahead of screening committee recommendation

A heated debate over targeted prostate screening has reignited after a charity published a report on the economic case for checks in high-risk men.

The report from Prostate Cancer Research, backed by former Prime Minister Rishi Sunak, called for a national screening programme for Black men and men with a family history of prostate cancer, which it said would cost the NHS £25 million a year.

The analysis involved ‘case-finding’ using PSA tests followed by MRI scans for those needing further investigation.

But critics noted that the expense is not the key barrier to introducing screening in the UK but whether or not the benefits outweigh the harms.

It comes amid heightened speculation over updated recommendations from the National Screening Committee (NSC) expected later this year.

The Department of Health and Social Care (DHSC) refused to be drawn on reporting in The Times earlier this month that NHS advisers are expected to rule against routine screening for prostate cancer, despite prominent campaigns.

NSC members have been looking at modelling of a range of options, including a more targeted approach, but The Times reported that they are expected to conclude that the harms still outweigh the modest benefits.

The NSC said it had come under increased pressure in recent months to reconsider PSA testing policy, particularly after Sir Chris Hoy’s announcement that he had been diagnosed with terminal cancer.

A study published in the BMJ earlier this month found the current approach to PSA testing may not ‘effectively target’ those most likely to benefit while others are having multiple tests without symptoms.

The UK researchers said ‘unpredictable surges’ in PSA testing as well as overtesting may also be the result of high-profile celebrities sharing their cancer diagnoses and calling for screening.

Their analysis of GP records from more than 10 million men over the age of 18 years between 2000 and 2018 found 1.5 million men had at least one PSA test during the study period, resulting in 3.8 million PSA tests overall. 

Testing increased fivefold during the study period, they reported in the BMJ, particularly in men without symptoms and those with PSA values below recommended thresholds. 

The highest testing rates occurred in men aged over 70 years who are least likely to benefit from repeat testing, and a substantial portion occurred in men under 39 years – much younger than recommended.

Almost half of men were retested but more than 75% of those had no symptoms recorded and 73% never had a PSA value above the recommended threshold, the data showed.

They added with home-based PSA testing kits now available through private providers ‘we anticipate increased testing in this age range’ and group of patients may ‘experience harms of overtesting’.

Previous research has shown wide variation between GP practices in use of PSA testing in men who are asymptomatic for prostate cancer.

Health minister Wes Streeting has said he is in favour of a national screening programme but would be led by the evidence.

A DHSC spokesperson said: ‘The evidence is still being considered and it would be inappropriate for anyone to try to predict any potential recommendation before it is made.

‘This government has been clear it would like to see screening in place, but the decision must be evidence-led.’

The NSC has commissioned modelling to look in more detail at the harm to benefit ratio of testing including taking into account repeat screening.

Experts expect that the £42m TRANSFORM trial launched last year to test different screening approaches including genetic testing, fast MRI scans and PSA, will provide more clear answers in a couple of years.

Professor James Catto, professor of urology at the University of Sheffield, said we know we can find prostate cancer if we use PSA tests and MRI scans, but the challenge is to find the cancers that would affect the man in his lifetime.

He also pointed to the UK IMProVe trial looking at PSA values and different types of MRI scan.

He said: ‘We don’t yet know the best approach to do this. Previous trials of prostate cancer screening have found too many men with the slow growing cancers, and have led to potential harm.

‘It is better to find the best approach rather than start testing immediately and risk harming men and overwhelming hospitals.’

Professor Willie Hamilton, professor of primary care diagnostics (cancer) at the University of Exeter, said: ‘We know there’s a real issue with the current situation, including huge variation in testing men without symptoms, so some clarity and consistency of guidance would be welcome.

‘We need to make progress on prostate cancer, but screening isn’t necessarily the best way forwards.’

But Professor Nick James from the Institute of Cancer Research said the case for prostate cancer screening was getting ‘increasingly strong’.

Targeting high risk groups – such as those with genetic risk, those living in deprived areas where men often present late and Black men, would be a place to start, he explained.

‘Our group have shown via our Man Van program that we can identify these groups, and they will participate in health check programs if given suitable information packages.’