PSA Testing Conducted & Supported by The Graham Fulford Charitable Trust

June 2016

To Screen Or Not To Screen – That Is The Only Question

Prostate Cancer (PCa) is the commonest major cancer in UK men and second commonest cause of cancer deaths with 47,000 new registrations and 11,000 deaths each year1. This is one of the highest death rates in the world despite our having one of the world’s richest economies. Furthermore, death from disseminated, “metastatic” PCa is almost always thoroughly unpleasant. Yet such deaths are largely preventable through early detection and curative treatment of “localised” PCa still confined within the prostate gland.

Early detection since the early ′90s has been achieved by the screening blood test Prostate Specific Antigen (PSA) which has dramatically reduced the number of men presenting with advanced, incurable disease. However, the UK National Screening Committee (NSC) states that PSA is too inaccurate for population screening and that the burden of harm from “over-diagnosis” and “over-treatment” of non-lethal PCa outweighs the benefit of cure for a minority with early aggressive disease2. Consequently, as there is no cheap, simple alternative to PSA on the horizon, Public Health England has published a revised Prostate Cancer Risk Management Programme (PCRMP) to inform GPs and men of the benefits, limitations and risks of PSA screening3.

Unfortunately the PCRMP is not comprehensive and contains outdated information that discourages screening whilst failing to quote beneficial information from the latest PCa screening trials 4,5 or best practice multinational screening guidelines6,7,8,9. More confusing and paradoxical, the PCRMP has recommended a reduction from 4 to ≥3 ng/ml as the new referral threshold for men aged 50-69. This may well lead to more “over-diagnosis”, not less!

The UK relies upon GPs to deliver counselling and screening for men requesting a PSA test. Recent research confirmed that only a quarter of GPs were familiar with the previous PCRMP10 and many men requesting the test have been fobbed off with inadequate or unbalanced counselling.

Although UK men aged 50-69 have a legitimate right to have a PSA test, only 8% do so and amongst socio-economically deprived groups that figure is much lower. This is a particular concern for black African and African Caribbean men who carry a 1 in 4 risk of developing PCa and for men with a positive family history11.

Finally, despite awareness campaigns raising the profile of PCa, most research funding is directed towards the search for new markers and drugs for incurable disease, rather than intelligent, pragmatic use of the tools we already have available for early detection, discrimination between aggressive and non-aggressive disease and the cheaper option of early, curative treatment.

It is thus not surprising that UK PCa statistics are so poor, but what evidence is there to counter the anti-screening rhetoric?

In 2014 The British Journal of Urology International (BJUI) published its “Guideline of Guidelines” which reviewed all the major national and international urological guidelines on screening and early detection12. All unequivocally recommended that men “at risk” should be in a screening programme from their mid-forties and that all men aged 50-70 should be provided with balanced information on which to make an “informed decision” whether to be screened or not. UK men don’t get this choice despite randomised clinical trials now showing up to a 50% fall in PCa mortality rates for men who are screened5.

Furthermore, the risks of over-diagnosis and over-treatment are being overcome by advances in specialist UK practice: increasingly better utilisation of PSA, introduction of second-line markers, increased use of MRI imaging before biopsy, reduced numbers of inappropriate biopsies, better selection of biopsy techniques and, most importantly, a rapid growth in the use of surveillance alone for non-aggressive cancers. Consequently the old bogies of “over-diagnosis” and “over-treatment” are simply no longer a major problem in UK urological practice.

Care in UK urology cancer centres is as good as any in the world but far too few UK men get access to this excellence soon enough.

We now need to bridge the gap between primary care and our excellent specialist services by taking the following steps:

Raise awareness of PCa.
Raise awareness for men at risk.
Educate commissioners, GPs and primary care providers on the benefits of PSA testing11.
Introduce a commitment to baseline PSA testing in primary care.
Introduce risk profiling as an adjunct to simple PSA testing.
Ensure the availability of best practice (MRI) imaging prior to prostatic biopsy.
Promote existing best practice urology guidelines for the early detection and treatment of significant PCa.

These steps are organisational in nature and none relies on a medical breakthrough or huge investment; in fact early, curative treatment is far cheaper than treatment of advanced disease.

In conclusion, to take significant steps now to reduce the current, unacceptable UK death rate from PCa, we need to increase enormously Primary Care based PSA screening to appropriately informed men. Because of the static and conflicted PCa screening situation in the UK, we believe that impetus and ultimate change of direction now requires a political decision and wish to enlist your support for such an initiative.
References:

Cancer Research UK. Cancer incidence – prostate cancer. Accessed April 2016.
Louie K S. UKNSC Screening for Prostate Cancer Review 2015 update. UK National Screening Committee, 2011.
Prostate Cancer Risk Management Programme (PCRMP): benefits and risks of PSA testing. Public Health England, 29th March 2016.
Hugosson et al. Mortality results from the Goteborg randomised population-based prostate cancer screening trial. Lancet Oncol 2010; 11:725-32.
Bokhorst L P et al. Prostate-specific Antigen Based Prostate Screening: Reduction of Prostate Cancer Mortality After Correction for Non-attendance and Contamination in the Rotterdam Section of the European Randomized Study of Screening for Prostate Cancer. European Urol 2014, 65(2): 329-336.
Guidelines on Prostate Cancer. European Association of Urology (EAU); updated March 2015.
American Urological Association (AUA). Early Detetion of Prostate Cancer: AUA Guideline: http://ww.aua.net.org/education/guidelines/prostate-cancer-detection. cfm. Accessed 12/4/16.
Murphy D G et al. The Melbourne Consensus Statement on the early detection of prostate cancer. BJU Int 2014; 113: 186-8.
BAUS Response to the UKNSC consultation on prostate cancer screening. March 2015.
Hultin S et al. Audit of PSA requesting practices in primary care compared to guidelines established by the PCRMP in the Avon region of SW England. J Clin Urol 2014; 7(1); 45-54.
A summary of the PCRMP and Prostate Cancer UK’s Consensus Statements on PSA Testing: Information for GPs. March 2016.
Loeb S. Guideline of guidelines: Prostate cancer screening. BJU Int 2014; 114: 323-325.


C M Booth, MBBS, FRCS
Clinical Director
CHAPS Men’s Health Charity
April 2016


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