PSA test for prostate cancer

The pros & cons of a national screening programme

The UK has no national screening programme for prostate cancer. Screening for prostate cancer, which offers a PSA test to healthy men without symptoms, is controversial. Although studies have shown that mortality rates for prostate cancer are reduced by screening - the treatment for prostate cancer can cause serious harm to men. Most doctors and researchers still believe the harms of screening outweigh the benefits.

Survival statistics represent the length of time men know they have a condition. If more men are diagnosed earlier, their length of survival with cancer will appear to improve, simply because they have been aware of their diagnosis for longer. This is called 'lead time bias'.

In the United States death rates from prostate cancer have decreased, but it is not known if the reduction in death rates is due to screening or some other factor, such as improvements in treatment. In the USA, regions with different rates of prostate cancer screening and treatment have similar death rates for prostate cancer. Prostate cancer death rates have also declined in countries where PSA screening is uncommon.

Some of the men we talked to showed they understood why screening for prostate cancer hasn't been introduced in the UK. If prostate cancer is diagnosed there can still be much uncertainty about treatment, not least because the side effects of treatment are unpleasant. 

A few men, particularly those with a medical background (Interviews 01, 02, 41), were strongly against screening for the present. 

No screening test is 100% accurate, and all screening can lead to anxiety. One of the reasons why PSA screening is so controversial is that an abnormal PSA test does not always mean prostate cancer is presentAnd men with a normal  PSA test can still have prostate cancer. Many of the men we interviewed said that screening for prostate cancer using the PSA test could lead to anxiety because of this. 

The task of The UK National Screening Committee is to review research evidence and make recommendations on whether screening programmes should be implemented. A screening programme will not be recommended unless there is clear evidence that such a programme will do more good than harm. The committee has not recommended PSA screening in the UK at present, partly for the reasons given above, and also because there are different types of prostate cancer, some which kill and some which appear to remain dormant throughout a man's life. Probably more than a third of men in their 80's have 'latent' prostate cancer, yet it develops in only very few of them before they die. 

At the moment it is not possible to identify which prostate cancers are of this 'latent' variety. The biopsy may give some indication of whether or not the cancer is likely to be slow growing, but grading systems, such as the Gleason score, are not very accurate. If all men were screened for prostate cancer a proportion of men with the types of cancer that would not develop symptoms, would suffer serious harms from treatments for such cancers. Thus on present evidence screening all men over a certain age in the UK might do more harm than good. 

A screening programme must minimise harm and maximise benefit. The National Screening Committee also has to make policy recommendations that will do more good than harm at a reasonable cost, focusing on opportunity cost; that is the professional time involved as well as the financial cost. Many of the men we talked to realised that costs and benefits must be balanced, and some mentioned the shortage of urologists and lack of money in the National Health Service.

Another man with a medical background also thought that cost had to be considered.  

In spite of the cost and other concerns about screening for prostate cancer many of the other men we talked to were in favour of a national screening programme. Some felt their lives had been saved because they had had a PSA test, and others said that they felt less anxious because they had been tested and had had a 'normal' result. Some men couldn't understand why the UK has screening for other conditions but not for prostate cancer. 

A few men felt strongly that all men over 50 should be offered a PSA test. One complained about the 'nanny state' and said that all men should be screened and given the opportunity to make an informed choice about treatment options. 

Another man said that he thought all men over 50 should at least be told about the PSA test because doctors don't make it clear whether or not urinary symptoms are due to prostate cancer or something else. He also pointed out that since cancer may be present without any symptoms screening may be beneficial.

Although some men told us that they would rather have slightly shorter lives than endure the side effects of treatment for prostate cancer, others thought that the side effects of treatment were worth risking in order to stay alive. 

Some men suggested that the PSA test should be part of routine health checks for men (over 50) similar to checks for blood pressure and cholesterol. One man recalled a time in the 1960's when he had nursed men with prostate cancer who had died a painful death, and he argued that just as blood pressure or cholesterol tests save lives, the PSA test might save lives too.

Large randomised trials have been conducted in Europe (The European Randomised Study of Screening for Prostate Cancer (ERSPC)) and in the USA (Prostate, Lung, Colorectal and Ovarian (PLCO) cancer screening trial) to assess the impact of screening and to compare three different treatment options - surgery, radiotherapy and 'active surveillance' for prostate cancer (detected at an early stage). These trials aim to help assess screening and different treatments and decide whether or not they reduce death rates from prostate cancer.

In the UK any man aged 50 and over can request a PSA test, providing he has read information about the risks and benefits of testing (see 'Finding information about the PSA test' and 'Deciding whether or not to have the PSA test'). 

Last reviewed May 2016.

Last updated May 2016.

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