Following a report in the Mirror yesterday of a massive rise in diagnosis of advanced prostate cancer in the United States and a call for more PSA screening there, our resident expert Dr Sophie Lutter cautions against such an approach here.
You may have seen an article in the Mirror yesterday: ‘Massive rise in prostate cancer cases spreading prompt calls for more men to be screened’. It may also be given further news coverage today.
PSA testing and prostate cancer screening is a hugely controversial issue, and one that we know causes a lot of men concern. So we wanted to make a few things clear about this article, and the research it’s based on.
First – and most importantly – this research was carried out in the United States. It showed that since 2007, the number of men diagnosed with advanced prostate cancer (that had spread outside the prostate) in the USA has increased. In the discussion of their results, the authors note that this increase in diagnoses of advanced disease began before routine PSA screening ended, although they do speculate that changes in screening behaviour before the regulations changed may have played a part.
They also speculate that the number of advanced disease cases being detected could be due to an overall increase in prostate cancer aggressiveness. Or – perhaps more likely – because improvements in imaging technologies are making it easier to diagnose advanced prostate cancers accurately. The authors suggest that that some refinements should be made to nationwide screening and treatment for prostate cancer – in the US.
It’s really important to note that the situation in the UK is very different to that in the States. These conclusions will not transfer across the Atlantic – they just don’t apply here. For a start, we have never had a prostate cancer screening programme, so we can’t draw any direct parallels to see how these results might compare in the UK
Secondly, the UK and US health systems are very different. In the UK, men who are proactive about their health can approach their GP for free before they have symptoms. We encourage men who are at higher than average risk of prostate cancer to do this from the age of 45, while current guidelines give men over 50 the right to a PSA test if they speak to their GP. In the US, given that a visit to a doctor or other healthcare professional will cost a man money, it may mean they wait until they have symptoms before seeking help, when the prostate cancer could already have progressed to advanced stage.
So once again, recommendations and conclusions based on US data are incomparable, and non-applicable, in the UK.
We do not believe that nationwide screening using the PSA test alone in the UK is in men’s best interests. On the one hand, PSA testing does not 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.
On the other, it results in a high number of false positives. A standard TRUS biopsy confers a high risk of infection, which could be anything from a urinary tract infection to sepsis. This means that a false positive can be more damaging than just a few anxious weeks before the all clear comes through. It could mean hospitalisation.
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.
That doesn’t mean that we think things are just fine and dandy as they are. They absolutely aren’t. Access to PSA testing across the country – and even from one GP surgery to another – is variable. This isn’t acceptable. We still don’t have a definitive way to diagnose men with aggressive prostate cancer earlier, while sparing men without cancer, or with harmless disease, from invasive and harmful diagnostic tests. This isn’t acceptable either.
But we are making progress towards addressing both these problems, and this is a top priority for us.
That’s why we 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, addressing some of the questions the PCRMP can’t answer.
It’s also why we’re so excited about the imminent publication of the PROMIS trial, and are already working to make sure that all the groundwork is laid to enable widespread access to multiparametric MRI before biopsy as soon as possible after the results have been peer-reviewed.
And finally, it’s why we plan to invest over £2 million into the development of a new risk assessment tool for GPs that should indicate the presence of cancer far more accurately than the current PSA test. This landmark research project – involving scientists from around the world – will not only help men understand their risk of aggressive prostate cancer, but also what to do about it.