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Scrap PSA policy for either population screening or symptomatic testing, researchers argue

Scrap PSA policy for either population screening or symptomatic testing, researchers argue

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.’


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Paul Loxton 26 May, 2023 10:06 am

This does not make any sense.
The problem is that as is well known ( but ignored) the PSA test is not suitable for screening .
It should therefore not be called a screening test .
GPs have a responsibility to stop doing this test in asymptomatic men .
Both the US and UK screening committees have rejected it.
How can one then move to a whole population model of screening without a reliable test?
It should be scrapped.
Unfortunately so much money is being made that it won’t be .
The unnecessary harm caused to a very large number of men since this test was introduced is one of the great recent medical scandals.

Neil Banik 2 June, 2023 9:28 pm

This makes perfect sense: as we have strong evidence that majority of prostate cancer are ASYMPTOMATIC and the more the LUTS/ bladder and peeing symptoms the less the chance you have cancer prostate. A paper by Gnananpragasam, Greenberg and Burnet (2022) found that symptoms do not equal risk of prostate cancer diagnosis but rather:  

There is no evidence of a causal link between prostate cancer and either prostate size or troublesome male urinary symptoms. In fact, most evidence points to an inverse correlation.  PSA testing should be encouraged in at-risk men: Modern image-based diagnostics and risk-adapted management strategies have reduced the risks of over-investigation and over-treatment which previously deterred greater promotion of PSA testing in men with no symptoms.  
Curable prostate cancer is asymptomatic: It is now timely to re-brand early, curable prostate cancer as primarily an asymptomatic disease to encourage more men to come forward and get tested earlier.   REF:

Jonathan Lenten 20 November, 2023 2:45 pm

I would agree that we should be offering the PSA test.

PSA is clearly a marker of Prostate Cancer.
Although other causes such as frequent fucking, strenuous physical exercise, BPH and UTIs are well known to increase the PSA level. So maybe we should recommend that men should abstain from sex for 6 months prior to the test otherwise they can’t have the test. I would postulate that this may well satisfy the non-male ½ of the population, although in truth, I suspect only a small proportion of men in the relevant age group would have to wait any significant length of time to have the test performed using this criteria anyway!

My understanding is that ~1 in 40 men in the UK will die of Prostate Cancer.
So logically, anything that can help identify the diagnosis earlier will increase the ‘cure’ rate and reduce the morbidity rate and hence the expense to this great nation of ours.

Our job as GPs are to identify those with the diagnosis or those we think could have the diagnosis and then refer to the appropriate specialist to appropriately manage that individual.
I believe checking a PSA level can help do that.

I fully understand certain individuals clearly believe that prolonging the lives of old cantankerous men is of no benefit. After all, men as a species do not live as long as the other principle biological gender, and as they are going to die sooner anyway, why try and save these useless, superfluous individuals that only put an additional drain on our society’s resources.
“Let the ‘fuckers’ die with it, as they’ll ‘probably’ die of something else first anyway”