Sophie Lutter explains what we're doing to improve the availability of PSA testing to men who want or need it and why, on its own, it's still not the answer to creating a national screening programme for prostate cancer.
It’s unacceptable that access and attitudes to the PSA test vary so much across the country. It’s unacceptable that awareness of prostate cancer risk factors is so variable among health professionals. And it’s unacceptable that the best course of action for men concerned about prostate cancer, and their GPs, is less than black and white.
This isn’t something that can be fixed overnight. Decades of research has not yet been able to answer – with any degree of satisfaction – the fundamental questions about which men would most benefit from a PSA test, at what age to have a first test, and how often to repeat the PSA test if the score isn’t high enough for an immediate referral.
What the research has shown, very clearly, is that we cannot achieve the outcomes we want – earlier detection of aggressive prostate cancers and reduced testing and treatment for non-harmful prostate cancers – by implementing prostate cancer screening using the PSA test.
One of the major problems with widespread PSA testing is that it doesn’t catch all aggressive prostate cancers. A man can have a PSA test every year from the age of 50 and still be caught unawares by a diagnosis of advanced disease.
Another major problem is the high number of false positives. This isn’t just a case of a few stressful weeks before the biopsy gives you the all clear. A standard transrectal biopsy can be harmful in and of itself. The route the biopsy needle has to take (through the back passage) confers a high risk of infection – a systematic evidence review from 2013 showed that for 72,500 TRUS biopsies carried out in the UK, 2.15 to 3.6 per cent of men were readmitted to hospital with infectious complications. This could be anything from a urinary tract infection to sepsis. All for a test to diagnose a cancer a man may not even have.
On an individual level, for a man concerned about prostate cancer, a clear and upfront discussion about the pros and cons of PSA testing and biopsy can result in an informed and sensible decision that this is the right course of action for him. And we absolutely believe that every man has the right to exactly this sort of discussion and should have access to a PSA test if, on the basis of said discussion, he decides that’s right for him.
On a national scale, though, the risk of causing serious harm to otherwise healthy men as a result of testing for, and then treating, someone who either didn’t have cancer at all or didn’t have a form of cancer that needed treating is just too high for us to be able to promote a screening programme.
Ultimately, improving prostate cancer diagnosis is going to come down to more than the PSA test. So we’re looking at the bigger picture and taking a three-pronged approach.
1. Immediate action: improving PSA testing
We don’t just want things to be better in the future; we want them to be better now. That means making the best of what we’ve got, which is the PSA test. As I said earlier, research can’t tell us how best to use the PSA test, so we’ve asked hundreds of clinicians across the UK to give us the benefit of their expertise and come up with a series of statements that will act as additional guidance to accompany Public Health England’s newly updated Prostate Cancer Risk Management Programme, or PCRMP.
These statements will address some of the questions that the PCRMP can’t answer, like when men should be given access to baseline testing to help predict their future risk of prostate cancer, and whether Black men and men with a family history of prostate cancer should be treated differently. The clinicians decided they should. GPs should be prepared to have proactive conversations about PSA testing with these men so that these ‘high risk’ groups can make an informed choice about a PSA test from the age of 45.
We’re working to raise awareness of prostate cancer risk factors among GPs and, alongside the PCRMP team, to promote these two sets of guidelines to health professionals to increase early detection of aggressive prostate cancers and end some of the inconsistency around PSA testing once and for all.
You can read more about this work on our PSA consensus page.
2. The medium term goal: improving biopsy
A large scale, NHS-based clinical trial called PROMIS has been investigating whether a multiparametric (mp)MRI scan before a biopsy can reliably identify men without aggressive prostate cancer, so that they can safely avoid having a biopsy. The results are due to report this summer, but early indications are positive.
We’ve already started laying the groundwork for an early rollout of this technology as soon as possible after the results are published. We’re working with radiologists to understand what facilities and training are already in place for radiologists to carry out this sort of scan, and where it’s already being done around the UK. We’re also investigating what additional training and resources will be needed to make sure that there are enough scanners and enough radiologists with specialist training in interpreting prostate MRIs, to be able to get this new technology safely up and running throughout the country as soon as possible after the results are announced. This has the potential to significantly reduce the problem of causing harm to healthy men that PSA screening would currently create.
Read more about this exciting on our mpMRI project page.
3. The long term plan: investing in risk research
We’ve just invested in an international research collaboration to develop a risk prediction tool that can be used in primary care in the UK to identify men at high risk of aggressive prostate cancer. Importantly, this aims to not only tell a man what his risk is, but also what he should do about it. Whether that’s ‘go to the urologist immediately’, ‘come back in a year for another PSA test’, or ‘don’t worry – you won’t need another test for a decade’. We hope that GPs will be using this new test within the next three to five years.
Read more about this groundbreaking project in our recent news article.