The UK should either put in place a ‘risk-based’ screening programme for prostate cancer or make it clear people should not have a PSA test without symptoms, say researchers who argue the current system is not working.
‘Informed choice’ approaches where men can have a test if they ask their GP for one after the pros and cons have been explained has led to clear medical harm and inequity but with minimal benefit, an international team of researchers writing in the BMJ have concluded.
This is not just the UK, but common among many high-income countries that have chosen not to implement national population screening with PSA because of uncertainty on the benefits and harms, they said.
But the result of this ‘shared decision making’ approach has been an ‘uneven distribution’ of PSA testing among those who are wealthier and more educated, figures suggest.
In the UK, prostate cancer incidence has increased by about 50% since PSA testing became available in the early 1990s, the researchers pointed out.
But around 25-50% of men who have prostate cancer detected after PSA testing would have ‘lived out their natural lives’ without ever having being diagnosed, suggesting that overdiagnosis occurs in about 10,000 men in the UK every year.
The benefit of a comprehensive, risk-based prostate cancer detection programme for PSA testing, say in men aged 50-70, would be more targeted and equitable access but also allow for evidence-based guidance on diagnostic follow-up and treatment to avoid harms, they argued.
It could also reduce testing from current levels in some countries, with men with initially low levels followed up less frequently, the team wrote.
If that approach was not acceptable, a reasonable alternative would be a clear recommendation against PSA screening along with along with policies that make it hard to obtain a test without specific symptoms.
There could be a possible exception for a small number of men at high risk, but it is also the case that such policies are largely untested and would require further research, they concluded.
Earlier this year a charity said prostate cancer is ‘much less harmful’ than it used to be and the evidence on introducing a PSA screening programme should be reconsidered.
An analysis by Prostate Cancer UK and presented at the American Society of Clinical Oncology meeting in San Francisco claimed he introduction of MRI before biopsy as well as changes to the way biopsies are done has tipped the seesaw in favour of screening.
At the time a Department of Health and Social Care spokesperson had confirmed that the UK National Screening Committee had received a set of proposals relating to screening for prostate cancer which would be explored further.
Some experts have warned that the best way forward for PSA screening is still not clear. The 15-year results from the UK ProtecT trial in April showed that active monitoring of prostate cancer is associated with the same high survival rates as radiotherapy or surgery.
‘Although we believe that early detection of prostate cancer should involve shared decision making, the current approach of determining testing by shared decision making has resulted in the worst possible practical outcome of high levels of PSA testing and medical harm, with minimal benefit and inequity,’ the researchers said.
‘To make better use of PSA testing, policy makers should choose between a comprehensive, risk adapted approach that is specifically designed to reduce overdiagnosis and overtreatment, or restricting PSA testing to people referred to urologists with symptoms.’