May 17, 2023

expert reaction to a paper reviewing current prostate cancer ‘test by request’ policies

A paper published in The BMJ suggests that current policies on early detection of prostate cancer create overdiagnosis and inequity with minimal benefit.

Prof Derek Rosario, Consultant Urological Surgeon, Honorary Professor and Clinical Advisor (Prostate) to the UK National Screening Committee, said:

“Given the conflicting findings in large studies on screening for prostate cancer and ongoing uncertainties around PSA testing, I agree with the sentiment in this article, that informed choice and shared decision making is an appropriate strategy. The real problem lies in ensuring that men considering PSA testing understand they have a choice and are informed of the pros and cons before any testing is carried out. To this end, the patient information in the Prostate Cancer Risk Management Programme has been tested with patient representatives and edited accordingly. Furthermore, the UK National Screening Committee (UK NSC) is working with organisations such as Prostate Cancer UK to ensure public education and awareness of the pros and cons of testing is fit for purpose.

“In parallel, healthcare professionals need to be educated in the do’s and don’t’s of PSA testing – a reasonable starting point would be that no man (or person identifying as non-male but possessing a prostate) should have a PSA test carried out without their express consent.

“Educating the public and professionals to increase understanding of the risks and benefits of PSA testing and subsequent treatments of prostate cancer, including active monitoring, is likely to be more acceptable and effective than restricting access to testing based on arbitrary criteria.

“In response to the question as to whether the UK is ready to roll out prostate cancer screening, the UK NSC awaits the results of the Swedish pilot testing a different approach to screening based on risk assessment.

“The UK NSC received a number of proposals relating to screening for prostate cancer under its 2022 annual call for topics. It has decided these proposals should be explored further and is considering how best to take them forward.”

Dr Benjamin Lamb, Prostate cancer lead, Barts Health NHS Trust, said:

Is this a good quality analysis?  Are the conclusions/policy suggestions backed up by solid data/evidence?

“In my view, the authors have comprehensively reviewed policy across a number of countries in the context of evidence from screening trials. Their conclusion that much PSA testing is currently undertaken among age groups outside of screening trials with limited evidence of benefit is correct. They also conclude that some studies also suggest that current PSA testing is not systematic, comprehensive, or equitable, which is also reasonable, and may mirror known health inequity with a lack of identification of men at the highest risk e.g., in the black community.” 

How does this analysis fit with the existing body of evidence on prostate cancer screening?

“The analysis is sound as there are known benefits from risk-adapted comprehensive screening trials in men aged 50-70, but discordance with current practice, meaning benefits and harms are not those seen in trials.”

Are there important limitations to be aware of? Are there any pieces of evidence missing from the analysis?

“Many screening trials have not accounted for recent developments such as pre-biopsy MRI and active surveillance for low-risk cancer which further improves the risk-benefit ratio for comprehensive risk stratified screening. These have not been assessed in depth in the current article.

“Furthermore, screening trials often have under-representation of black men in their study participants with consequent difficulty in generalising these findings to ethnically diverse populations.”

What are the implications in the real world?  Is there any overspeculation?

“In either of the authors’ options, I think it is likely that older men who are well-informed and able to request a PSA test are likely to get one. In my view, the emphasis should be on engaging younger and at-risk men rather than restricting access for older men.”

What changes in policy are the authors suggesting? What is the evidence given to support their proposal?

“The authors suggest adopting risk-based comprehensive screening as the preferred alternative to the status quo, which they find, on balance, is harmful. Their proposed alternative, of restricting PSA testing, in my view, is not feasible.”

Professor Nick James, Professor of Prostate and Bladder Cancer Research at The Institute of Cancer Research, London, and Consultant Oncologist at The Royal Marsden NHS Foundation Trust, said:

“I agree with the authors and strongly support the implementation of a risk-based approach to PSA testing at a national level. There is an urgent need for a more equitable and targeted screening strategy, which could help address existing health disparities. Currently, individuals from economically disadvantaged backgrounds are less likely to undergo PSA testing. Men in their 50s or younger, who may stand to benefit more from these tests, are also less likely to receive PSA tests compared to older men who benefit less. Linked to better diagnostic pathways with MRI, already standard in the UK, potential harms from overdiagnosis and overtreatment can be mitigated.

“By adopting a risk-based approach, we can tailor screening efforts to those at higher risk of developing aggressive forms of prostate cancer that requires and benefits from treatment, while reducing unnecessary testing for those at lower risk of harm, minimising the potential damage associated with overdiagnosis and overtreatment.”

‘Current policies on early detection of prostate cancer create overdiagnosis and inequity with minimal benefit’ by Andrew Vickers et al. was published in The BMJ at 23:30 UK time Wednesday 17 May 2023.

DOI: 10.1136/bmj-2022-071082

Declared interests

Dr Benjamin Lamb: Current Prostate Cancer UK Clinical champion; Clinical advisor to Cambridge Clinical Laboratories. Previously received payment as speaker by Astra Zeneka and astellas. Previously received payment for training cancer teams from nhs cancer alliances and health education England

Professor Nick James: “With respect to prostate cancer diagnosis no COI.  I have done consultancy work for various pharmaceutical companies with prostate cancer products. Funding for prostate cancer research from academic, charitable and commercial sources. My current research includes the Man Van which is an outreach early diagnosis project.”

Prof Derek Rosario: “Nothing to declare.”