Promoting prostate cancer tests in men without symptoms should be approached with caution

Inviting people who don’t have symptoms to be screened for prostate cancer is not currently recommended and should be approached with caution because, for most men, the benefit is small and uncertain and there are clear harms, warn experts in The BMJ today.

NHS England teamed up with Prostate Cancer UK earlier this year to find the 14,000 men estimated to have not yet started treatment for prostate cancer because of the pandemic. However, experts warn that screening for prostate cancer is not currently recommended by the UK National Screening Committee.

The National Institute for Health and Care Excellence (NICE) advises GPs that “testing should not be offered to asymptomatic people”, although a test can be requested by a patient who has been made aware of the possible harms and benefits.

The campaign encourages men to use a ‘risk checker’ and if concerned, speak to their GP about possible next steps, including a prostate specific antigen (PSA) test.

But in the UK and the US, routine PSA screening is not recommended because research has shown that the test can, at best, prevent one prostate cancer death for every 1000 patients tested over 10 years.

PSA testing also carries a risk of overdiagnosis– healthy men being diagnosed and treated unnecessarily for slow-growing and harmless tumors.

While the authors acknowledge that the campaign’s message aligns with the established principle of allowing patients to decide for themselves on PSA testing, and the risk checker does provide some valuable information, they say encouraging all asymptomatic men older than 50 to book a GP appointment to discuss their risk “seems to depart from this cautious approach” and also has resource implications.

That the campaign encourages detection of asymptomatic disease could lead people to believe that the NHS is promoting screening, the experts add.

In the UK and the US, asymptomatic men can opt for a PSA test after exploring their options with their doctor. However, the experts suggest that reaching a shared decision on the value of a PSA test is complex and time consuming.

“GPs and patients need practical up-to-date guidance on PSA testing, including recommended evidence based tools and resources to support shared decision making,” write the authors.

“If a risk checker tool is to be promoted as part of an early detection strategy, the tool must be evidence based and evaluated appropriately.”

Better ways to detect prostate cancer earlier are being evaluated but in the meantime, “efforts must continue to focus on prompt diagnosis of symptomatic patients, and generating the evidence of the clinical and cost effectiveness, and safety of any national screening program,” they conclude.