The UK National Screening Committee will soon consider six different proposals for prostate cancer screening, including a targeted service for men at higher risk.
There is currently no screening programme for prostate cancer because there has not been enough evidence that the benefits would outweigh the risks.
However, chair of the UK National Screening Committee (NSC) Professor Sir Mike Richards confirmed yesterday that the organisation will ‘soon commission a major piece of work’ to consider six screening proposals that were submitted during its annual call for topics.
Professor Richards was responding to a new study which suggests MRI scans may be more accurate in identifying potential prostate cancer than the PSA test commonly administered by GPs.
MRI prostate cancer screening study findings
University College London (UCL) researchers gave both MRI scans and PSA tests to 303 men aged 50-75 who were identified by GP practices in London.
One in six of the men (48) had a positive screening MRI, of which 25 had clinically significant cancer, while two men had clinically insignificant cancer.
Two-thirds of those men who had a screen positive MRI had a PSA below 3 nanograms per millilitre (ng/ml). Currently, patients with results showing this level and above will be referred on for further NHS investigation.
The authors of the study said this finding is ‘a sobering one because MRI lesions are positively associated with clinically significant cancer’.
There were a further 16 men who had a raised PSA density alone, of which four men had clinically significant cancer.
NHS assessment therefore diagnosed a total of 29 men out of the 303 with prostate cancer, however over half (15) of them had a PSA result below 3ng/ml.
The researchers therefore suggest that using MRI to detect prostate cancer ‘can allow pick up of significant lesions before the PSA has begun to rise, and so offer an opportunity for early detection’.
They also recommend further research into the feasibility of MRI-led community screening, suggesting a mobile scanner such as those used in some breast screening programmes.
NSC chair Professor Mike Richards said: ‘The UK National Screening Committee notes with interest the findings of this study and how it might inform the future research that the authors realise is needed.
‘The committee does not currently recommend prostate cancer screening because there is no clear evidence that the benefits outweigh the harms.
‘The UK NSC will soon commission a major piece of work to consider 6 prostate cancer screening proposals that were submitted during its annual call for topics.
‘These include targeted and risk-stratified screening proposals for screening groups of men at higher risk due to factors such as ethnicity and family history.
‘In order to make any positive recommendation, the UK NSC would need to see high quality peer-reviewed research that demonstrates that a screening strategy would improve prostate cancer outcomes while minimising serious harms such as overdiagnosis, associated overtreatment and side effects.’
The NSC published its annual report last month and listed the six proposals which will form part of its wider work on prostate cancer screening risk stratification.
The proposalsProfessor Azeem Majeed, GP and professor of primary care and public health at Imperial College London
- Targeted screening proposal using prostate specific antigen (PSA) testing and high-risk factors, such as family history and ethnicity, to screen for prostate cancer
- Proposal to offer targeted screening for carriers of the BRCA2 gene
- Population and risk stratified proposal for a national programme based on the PSA test for all men aged 45 to 70, with frequency of testing stratified by individual risk calculated from an initial, normal PSA, age, ethnicity and family history, initially yearly for high-risk men and 3 to 5-yearly for low-risk men. Men with an abnormal PSA would be referred according to current 2-week wait and NICE criteria for mpMRI prostate scanning.
- Proposal for targeted screening of Black men aged 45 to 70.
- Targeted screening proposal to screen men between 50 and 69 with a Charlson co-morbidity index (less than or equal to 3) using the Stockholm3 blood test
- Targeted screening proposal to screen men aged 45 to 70 who have a first-degree relative diagnosed with prostate, breast or ovarian cancer (relevant family history).
Source: National Screening Committee
Professor Azeem Majeed, GP and professor of primary care and public health at Imperial College London, said that although there has been ‘pressure from some charities and urologists’ to implement a prostate cancer screening service in England, the NSC must ‘not be rushed into making recommendations’.
He said: ‘All PSA-based approaches to screening will result in false positive tests, which in turn can lead to unnecessary investigations, biopsies and treatment.
‘There is also the risk of false negative tests as shown by a recent study from University College London.
‘Ongoing research into novel screening methods, improvements in MRI technology, and refinements in risk stratification might eventually provide a more favourable balance of benefits and harms from screening – but would require substantial investment in equipment and staff.’
As such, England is still a ‘long way’ from seeing a national screening programme, according to Professor Majeed.
NHS guidance says that the risk of prostate cancer is higher in patients who: have a family history of the disease; are of black ethnic origin; or are overweight or obese.
Earlier this month, GPs – including one of NHS England’s medical directors – raised concerns about communication from the Government encouraging men over 50 to check their risk of prostate cancer, saying it was ‘promoting’ unofficial prostate cancer screening.
In February, the charity Prostate Cancer UK argued that testing is ‘much less harmful’ than it used to be and the evidence on introducing a PSA screening programme should be reconsidered.
And in May, an international team of researchers said the current system is not working, and that 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.
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 been diagnosed, suggesting that overdiagnosis occurs in about 10,000 men in the UK every year.
NHS England recently embarked on the first-ever national lung cancer screening programme, following a recommendation from the NSC last year.
READERS' COMMENTS [2]
Please note, only GPs are permitted to add comments to articles
There has been pressure from some charities and urologists to introduce prostate cancer screening in England. It’s essential that the National Screening Committee look at this topic in the same way as they would for calls for other screening programmes and not be rushed into making recommendations. This would require careful review of the scientific evidence, potential public health impact, costs, feasibility, and ethical considerations of prostate cancer screening.
All PSA-based approaches to screening will result in false positive tests, which in turn can lead to unnecessary investigations, biopsies and treatment. There is also the risk of false negative tests as shown by a recent study from University College London. Ongoing research into novel screening methods, improvements in MRI technology, and refinements in risk stratification might eventually provide a more favourable balance of benefits and harms from screening – but would require substantial investment in equipment and staff.
Hence, we are still a long way from seeing prostate cancer screening introduced in England and for now, men will continue to be diagnosed with prostate cancer through the traditional routes.
PSA screening of the general population has been commenced by some urologists and private companies, but is a complete mess.
GPs must do the screening at the correct time-intervals, but we do not know how often, and the pabs can’t even agree on the normal ranges.
6 Proposals?
1 – Screen all men
2 – that was too sexist – screen everyone
3 – compromise – only screen those who self-identify as men
4 – too discriminatory – screen all those who self-identify as not not-needing screening
5 – introduce an ageist discriminatory age-range for screening
6 – use primed hand-grenades for screening examination instead of a gloved finger, but make sure you exit the gas chamber (er I mean examination room) before a count of 5 – 4 – 3 – 2 – boom.
7 – give in and send all the blood in every patient for multi-cancer screening test.