A leading UK urologist has advocated all men over the age of 50 going to their GP for a PSA test.
Speaking on the Today programme on Radio 4 last week, Professor Hashim Ahmed, chair in urology at Imperial College London, said men aged over 50 years should go to their GP to get tested or over the age of 45 years if they were from a black ethnic minority or have a family history of the disease.
His comments were in response to a report from Prostate Cancer UK which found men in Scotland are almost three times more likely to be diagnosed at a late stage compared with men in London.
The North-South divide identified by the charity also found the next highest proportion of men diagnosed only at stage 4 was in north-east England and Yorkshire (20.1%), followed by Northern Ireland (20%), and Wales (19%).
Prostate Cancer UK are campaigning to raise awareness and call on GPs to proactively engage higher risk men about the PSA test.
Current policy from the National Screening Committee, last updated in November 2020, is that PSA testing for population screening is not recommended.
The committee said the evidence suggested that while whilst PSA-based screening is associated with increased incidence of prostate cancer diagnoses, the effect on prostate cancer-specific mortality in comparison with no screening remains unclear.
And that screening may be associated with overdiagnosis and biopsy-related complications.
‘Overall, it is not clear whether benefit gained from PSA-based screening programmes outweighs harms,’ the NSC concluded. Another review is due 2023-24 and research is ongoing to see if blood tests plus risk scores could be a more accurate approach to detecting early disease.
Under current Government policy PSA testing is available to any man over the age of 50 who requests it and is provided with information about the risks and benefits but GPs should not proactively raise it with asymptomatic individuals.
Professor Ahmed said at the moment it was reliant on PR messages around high-profile cases such as BBC presenter Bill Turnbill who died from prostate cancer in August 2022 to get messages about early detection out to the public.
‘And when they do go to their GP, their GPs don’t always encourage them to have a PSA test and often they can discourage them because they’re concerned about the disadvantages of investigating prostate cancer.
He added that specialists were much better at diagnosing the condition and avoiding a biopsy with MRI scans as well as having better treatments in place.
‘So that message to GPs that we are much better at diagnosing in a safer way, more accurate with minimally invasive treatments that confer less harm is the message we need to get out’, he said.
When asked what this meant for the general public, Professor Ahmed added: ‘Over the last decade we’ve been pushing this mantra that if you have urinary symptoms go and get tested but actually often urinary symptoms don’t reflect whether you have prostate cancer and if the urinary symptoms are due to prostate cancer its almost too late.
‘So go and get tested if you’re 50 or above. If you’re from a black ethnic minority or have a family history start getting tested from the age of 45.’
He added: ‘Until we have a national screening programme where the government sends out a letter and says please have a PSA blood test, and that’s going to take a while to get that sort of national breast cancer type screening programme going, we are heavily reliant on men being proactive.’
Dr Margaret McCartney, a GP in Glasgow and founder of the RCGP overdiagnosis subgroup, said comments on PSA testing for everyone should not have gone unchallenged in the interview.
‘I would like them to answer: which patients do they think should wait longer in order for us to do this work? Why are they expressing going against government advice? Why are they not referring men to NHS advice on PSA screening and instead using their own? What research have they done into the use of their guidance?
‘I am very disappointed that media outlets have not challenged these positions.’
Asked for comment, a DHSC spokesperson said prostate screening was due to be reviewed by the screening committee as part of regular proceedings during 2023/24.
READERS' COMMENTS [18]
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I am disappointed that Professor Ahmed has fired off this salvo with his pistol half-cocked.
He should have engaged with the screening committee before going public.
His actions can bring the profession into disrepute through giving only half-baked advice.
How often after age 45/50 should PSA screening be done?
What should be done with results at what level?
Should all men be screened from 45, rather than discriminating against white men?
What will be the effect on the urgent urology waiting list, which I think is about 2 years locally at present?? Or is he offering to handle and manage personally all the not-perfectly-normal PSA results that this brings in ?
Maybe we should refer all abnormal psa results to him on ERS and see what his comments are then. Hopefully his colleagues have something to say about this .
I agree with David Church, whilst prostate cancer is a significant problem PSA testing is not the answer and this is clearly demonstrated by the fact that that despite the huge difference in the rate of early detection in England and Scotland the age standardised mortality is the same. IMO we need a test for the aggressive form of the disease and a treatment that works. Then we can have a screening program. PSA Poor Screening Activity. Until then we are frightening and damaging men, using up precious NHS resource for no good reason. This is a disastrous story at the worst possible time.
Setting aside the clinical issues involved in PSA testing in asymptomatic men, this is a Public Health matter and is not GMS so it is not currently being funded and puts individual GPs in an impossible position. Proper pre -psa counselling takes at least 20 minutes and this ‘spare’ capacity simply does not exist
Not against PSA testing -we do loads.
But how often?
Resourcing?
Why not call for a much needed national screening program, rather than encouraging a free for all and putting more pressure on GPs.
On the upside, this should be less of a problem with Wes Streeting as they’ll be able to self refer to urology for their PSA anyway?!
Dear All,
What an uniformed expert! Lets hope he’s ignored.
Regards
Paul C
The problem here is that NICE says all men overnight 50 should have a PSA test if the ask for it. But there is no screening service at present. The reason for the change is the improvement in MRI screening of prostates. NICEs idea is to keep quite about it and only do for the few 50 odd year olds who ask. Unfortunately this then balloons into a full blown all 50 year old + asking for it and it becomes an unfounded screening service by default consultation blocking GP.
All men over 50 should ask their Urologists for a PSA test, leading GP urges.
No this comment is just ridiculous.
Their time is far too important to be used for a non-resourced, unfunded, public health intervention with questionable evidence at a population level.
Best just tell them to visit their local GP instead.
As ill thought out as this daft idea is, I did enjoy the Prof stating we were reliant on PR messages……
Doing psa in asymptomatic patient bring unnecessary anxiety . Raised psa does not equate ca . We have legal obligation to refer. Urologist will do biopsy which can cause complications and may result in negative test. Consultation and doing test need gp’s time . If you wish screen then do it as you do for bowel ca and breast ca. not in primary care.
Referral to Prof HA
The following lis tof patients have presetned to the GP surgery for screening which you have suggested. Whilst not agreeding or disagreeing on the effectiveness of this test, I can point out that population screening is not part of the GMS contract.
Therefore would you please see the following 200 patients in clinic, consent then for screening, examine them, perform a PSA test and give them appropriate feedback and follow up.
Alternatively do you job properly and engage the people with bags of money to start a screening program. GPs are not a workload dump because:
“that’s going to take a while to get that sort of national breast cancer type screening programme going”
kr
GMS GPs.
This would blend in nicely if Mr Starmers proposal to allow patients to refer themselves directly to secondary care comes to pass.The urology consultants could then handle the blow back .Methinks this particular urology specialist is taking the piss!If he is serious about this proposal he should involve people who can provide appropriate staffing and commensurate funding.ie not primary care units.
Thought you might like to know what goes on in the Colonies: –
Prostate-specific antigen (PSA) test – Canadian Cancer Society
Canadian Task Force recommends against screening for …
If you are at average risk of developing prostate cancer, consider testing from age 50. If you are at high risk of developing prostate cancer, consider testing from age 45. Black men (including men of African or Caribbean ancestry) and those with a family history of prostate cancer are considered to be at high risk.
Canadian Task Force on Preventive Health Care
·
For men younger than 55 years of age and 70 years of age and older, CTFPHC strongly recommends against screening for prostate cancer with the PSA test. There is …
Canadian Urological Association recommendations on … – NCBI
PSA: prostate-specific antigen. For men with PSA <1 ng/ml, repeat PSA testing every four years (Level of evidence: 3; Grade of recommendation: C). For men with PSA 1–3 ng/ml, repeat PSA testing every two years (Level of evidence: 3; Grade of recommendation: C).
If the test was actually useful and a test at 50 for everyone tells them they haven’t got cancer today (it doesn’t but let’s pretend it is better than it actually is)
Then that is all it tells you, that they have not got cancer at 50. Well hardly any men at 50 will have prostate cancer.
Even a couple of months later that test is no longer protective of prostate cancer.
So exactly how frequently does the Prof want us to test all men over 50? Or was his bright idea just 1 test at 50?
When you put his name into google the first thing thing that comes up is his private rooms at the Cromwell hospital !
Canadian recommendations…
Grade of recommendation C: Case series, low-quality cohort or case-control studies
Level of evidence 3: Systematic review of (homogeneous) case-control studies
Not particularly convincing.
Also Cochrane says:
Prostate cancer screening did not significantly decrease prostate cancer-specific mortality in a combined meta-analysis of five RCTs …. Pooled data currently demonstrates no significant reduction in prostate cancer-specific and overall mortality. Harms associated with PSA-based screening and subsequent diagnostic evaluations are frequent, and moderate in severity. Overdiagnosis and overtreatment are common and are associated with treatment-related harms …. Any reduction in prostate cancer-specific mortality may take up to 10 years to accrue; therefore, men who have a life expectancy less than 10 to 15 years should be informed that screening for prostate cancer is unlikely to be beneficial.
This is why GPs should be paid for activity, not for having a list of patients and producing realms of pointless audit data.
This is why everyone should pay, according to their means, for GP appointments.
Far too many men present with advanced disease via A&E and the current GP based ad hoc system fails these men. In terms of the screening evidence, the updated results of the European screening trial support screening with PSA and MRI based assessment of abnormal results. The EU just issued a new review of the screening evidence and is now recommending all member states establish screening for prostate cancer. Of course with Brexit we are free to continue to fail far more men than our EU neighbours with better cancer outcomes. Full details here https://ec.europa.eu/commission/presscorner/detail/en/qanda_22_5584