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Call to ditch ‘test by request’ approach to prostate cancer care

Academics have called for a change in the way men are tested for prostate cancer, warning the current “test by request” policies can drive health inequalities and lead to cases of “overdiagnosis”.

Experts said that many high income countries, including the UK, do not have a national screening programme for prostate cancer.

Instead men without symptoms can, if they wish, get a prostate-specific antigen (PSA) test after consulting a doctor.

Screening for prostate cancer has been heavily debated in medical circles due to potential harms including side effects from biopsies and unnecessary testing for those with no “clinically significant” cancer.

Writing in The BMJ, a group of international experts, including Professor James Catto from the University of Sheffield, said these sorts of requests have led to “high rates” of PSA testing, especially among men over the age of 70 who are “particularly prone to overdiagnosis but do not benefit from screening”.

In the UK, men aged 80-89 are twice as likely to get a PSA test as men in their 50s, they said.

A large proportion of people with prostate cancer “would have lived out their natural lives without a prostate cancer diagnosis”, they said.

This is because some people with the condition can simply live with prostate cancer without even knowing it is there.

The paper highlights how in the UK there are around 52,000 cases a year.

But the authors added: “Around 25-50% of men who have prostate cancer detected after PSA testing would have lived out their natural lives without a prostate cancer diagnosis, suggesting that overdiagnosis occurs in about 10,000 men in the UK every year.”

“In current routine care — and despite guidelines to the contrary — most men with an abnormal PSA result have prostate biopsy, even though only a minority will have aggressive prostate cancer,” they wrote.

“Furthermore, most men with biopsy detected cancers have either surgery or radiotherapy even if they have low risk tumours that are unlikely to cause cancer related morbidity or mortality.”

Surgery and treatment can also carry the risk of long term urinary, erectile, and bowel dysfunction as well as fatigue and loss of libido during treatment.

“Men who are overdiagnosed thus often experience treatment harms without receiving any benefit,” they added.

Meanwhile, the shared decision making approach to prostate cancer testing has led to “an uneven distribution, with higher rates of PSA testing among those who are wealthier and more educated,” the authors added.

They concluded that countries should introduce a “comprehensive, risk based, prostate cancer detection programme that is carefully designed to reduce overdiagnosis and overtreatment would reduce harm” and could possibly consider restricting PSA testing to people referred to specialists due to symptoms.

Commenting on the paper, 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.”

Chiara De Biase, director of support and influencing at Prostate Cancer UK, said: “It’s clear that the current system which requires men to request a PSA blood test for prostate cancer is flawed – but without a national screening programme, it’s the best we have.

“That’s why Prostate Cancer UK has developed a risk checker to help men make an informed choice as to whether to get tested.

“This is essential, because early prostate cancer doesn’t usually have symptoms, and stopping men getting tested unless they have symptoms would lead to more men being diagnosed too late to be cured.

“This report adds to evidence that the balance has now tipped in favour of an organised screening programme – particularly for those at highest risk, which includes black men and men with a family history, who are at double the risk from the disease.

“That’s why we are so pleased that the National Screening Committee is going to review the evidence and we hope this will lead to a targeted screening programme for these men in the near future.”

A Department of Health and Social Care spokesperson said: “The UK National Screening Committee is considering a variety of proposals related to screening for prostate cancer.

“It will explore these further and consider how best to take them forward.”

– Prostate Cancer UK’s 30 second risk checker can be found at prostatecanceruk.org/riskcheck