PSA Consensus 2024

Background

We commissioned a project to deliver a new consensus on the best use of the prostate-specific antigen (PSA) blood test in asymptomatic men in the UK.

The consensus was produced with the involvement of men with lived experience and an expert clinical / academic panels.

Right now, PSA testing guidelines for primary care and men are outdated:

• Guidelines are based on an outdated evidence-base and clinical trials that tested the old prostate cancer diagnostic pathway, i.e. PSA test, then biopsy.
• They do not provide clear guidance on highest risk men (Black men, men with a family history of prostate cancer and men with BRCA2 gene variations).
• NICE 2019 guidelines: recommend pre-biopsy multiparametric MRI (mpMRI) and active surveillance for men in Cambridge Prognostic Group (CPG)1 and CPG2 risk groups, making the prostate cancer diagnosis and treatment pathways safer and more accurate, whilst reducing the potential for over-treatment.

Guidelines also have the potential to exacerbate health inequalities because, although the PSA test is freely available on the NHS, it is recommended that GPs do not proactively raise the issue of PSA testing with asymptomatic men. 

This benefits only men who know about the PSA test and request it (frequently the most health literate and affluent). This has resulted in uneven PSA testing rates in the UK with evidence showing that men living in the South, and the least deprived regions, have higher PSA testing rates.

The consensus from the current study challenges previous PSA testing policy. It recommends proactive approaches in men at higher-than-average risk but does not go as far as recommending population or targeted screening.

Highlights 

The consensus has highlighted several areas where changes to policy and practice should be considered.

Awareness

There is a need to raise awareness of prostate cancer among men aged 50+, or from aged 45 for Black men and men with a family history of prostate cancer.

Responsibility for raising awareness of prostate cancer is shared by charities, the NHS (primary and secondary care), Governments, and public health bodies.

Primary Care

Trained health professionals can counsel men on the PSA blood test – not just GPs, offering the potential to widen access for men who want to discuss the pros and cons of the PSA test.

Men with a PSA level above the referral threshold (≥3.0ng/mL) do not need to have a DRE prior to referral to secondary care. Evidence suggests DRE has limited benefit as a screening tool in primary care, and is a known barrier for some men coming forwards for prostate health checks, believing it is the first and only test for prostate cancer or feel anxiety, shame, or embarrassment about it.

Primary care professionals should proactively discuss prostate cancer risk, PSA testing, and the wider diagnostic pathway with

• Black men ≥45
• Men with family history of prostate cancer ≥45
• Men with confirmed genetic risk factors for prostate cancer e.g. BRCA2 gene variation.

Men should be given balanced information on the pros and cons of the PSA blood test and supported to make an informed choice whether to have one. [That information can come from trained health professionals, charities, or can be delivered via validated online tools to support informed choice].

All informed men should have the potential to access the PSA blood test from the age of 50 years.

Black men

Primary care health professionals should proactively discuss prostate cancer risk, PSA testing and the wider diagnostic pathway with men over the age of 45 at higher-than-average risk of prostate cancer due to Black ethnicity.

Furthermore, it's strongly recommended that for Black men with a known family history of prostate, breast or ovarian cancer – in particular if a first degree relative has died at a young age of this cancer – the PSA blood test should be proactively discussed from the age of 45.

Readiness for screening in the UK

Statements on readiness for screening, or targeted screening, were far from consensus - some strongly agreeing and others strongly disagreeing. Concerns around overdiagnosis and overtreatment associated with PSA testing remain. For now:

• The PSA blood test is the first step in the prostate cancer diagnostic pathway. It is a cheap, safe, and effective way of identifying men who would benefit from further testing – in the first instance an MRI scan.
• The balance of benefits and harms is shifting in favour of screening, but evidence gaps remain, and more research is needed.
• To tackle inequalities of access and reduce burden on primary care, the NHS should commission services that enable men at risk of prostate cancer to access PSA testing outside of primary care.

There is a clear need to develop an effective prostate cancer screening programme to reduce the substantial number of late-stage diagnoses, whilst reducing overdiagnosis of non-aggressive cancers. Future research should prioritise discovery and validation of pathways that:

• Find aggressive cancers which are currently being missed.
• Further reduce harms (unnecessary biopsies, detection of clinically insignificant disease) in men who undergo PSA testing through informed choice.
• Allow for better risk stratification of men who undergo PSA testing through informed choice.

This is why we're funding the TRANSFORM trial, to find the best way to screen men for prostate cancer, so one day all men at risk are invited for regular tests to find aggressive cancers in time for a cure.

"As a GP, it's frustrating that current Department of Health & Social Care guidelines on PSA testing in men without symptoms provide very limited detail for us and our patients. It is unclear what should be done for men at higher risk of prostate cancer, how often men who choose to have the PSA blood test should have one, and when it would be in a man’s best interest to stop testing.”

"There has long been disagreement about the benefits and harms of the PSA blood test. However, with the publication of this new paper, we've shown there's broad agreement among the top minds in urology and prostate cancer care that the PSA blood test is simple and safe – and that GPs should consider proactively discussing the test with Black men and men with a family history from the age of 45."

- Dr Sam Merriel, one of the authors of the paper, GP, and Academic Clinical lecturer at the University of Manchester

“Before I was diagnosed, I had no idea that as a Black man I was at double the risk of prostate cancer.

“Thankfully, I was diagnosed early, before it spread beyond the prostate, but I know a lot of men aren’t so lucky. That’s why I’ve spent the years since working to raise awareness and offer support to men in Wolverhampton with prostate cancer, with a particular focus on Black men.

“When I heard about the chance to be involved in this project and help highlight how this disease really impacts men who are diagnosed, I knew I had to get involved. Too many Black men are simply never told about their risk of the disease. That’s why I support the findings of this paper and Prostate Cancer UK’s calls to change guidance so GPs can start having more potentially lifesaving conversations."

- Junior Hemans, from Wolverhampton, was diagnosed with prostate cancer in 2014, at the age of 51 as part of a routine health check. He was part of the panel of men with lived experience of prostate cancer who shared their stories to support the drafting of the PSA Consensus paper.