PSA Testing - the Tackle View
The Tackle Board supports the approach to PSA testing outlined below by Chris Booth, a member of our Clinical Advisory Board.
PSA Testing: A More Informed Approach
Since PSA came into general use in the 1990s, controversy over its benefits and harms have led to widely varying rates of use across different countries, and to differences of opinion between professionals and patients. This has happened largely because, although many PCas are not aggressive or lethal, PSA-based screening has led to invasive investigation and ‘over-diagnosis’, followed by ‘over-treatment’ through radical surgery or radiotherapy and their associated complications of impotence, incontinence and bowel disturbance. It is equally true, however, that many thousands of men have avoided a slow and painful death through the early treatment of PCa that was detected by PSA screening.
There have been many PCa screening trials in many countries over many years, trying to clarify the ‘benefits versus harm’ controversy, with varying results1,2,3. This has led to medical policy-makers making decisions on national policies for PSA screening on inadequate data4. For instance, in 2012 the United States National Preventive Services Task Force advised against PSA testing for any asymptomatic men5 but, since then, the death rate from metastatic PCa has started to rise, and we understand this guidance is now being reconsidered. .
PCa is the commonest major cancer in UK men and second commonest cause of cancer deaths with over 47,000 new registrations and over 11,000 deaths each year6. This is one of the highest death rates in the world even though we have one of the world’s richest economies. However, the UK National Screening Committee (NSC) argues that PSA-based screening is too imprecise and that the dangers of ‘over-diagnosis’ and ‘over-treatment’ outweigh the benefit of cure for a minority of men with early, aggressive disease4.
Nearly all current major national and international urological guidelines recommend PSA-based screening for appropriately selected, counselled men who can then make an informed decision7,8,9. In summary, the majority of international expert panels recommend or propose:
UK Clinical Practice
Finally, despite awareness campaigns raising the profile of PCa, the low rate of PSA testing has led to few opportunities to use the tools we already have for early detection and discrimination between aggressive and non-aggressive cancer; and the cheaper option of early, curative treatment compared with late, expensive, palliative and often unsuccessful treatment of advanced cancer leading to 11,000 deaths each year.
Against this background it is not surprising that UK statistics are so poor in comparison with the best trial results of screening that are being reported from Europe, where they have achieved 40-50% reductions in PCa mortality.13,14
To this more optimistic outlook we can now add the recently published evidence from two hugely significant UK trials: the PROMIS Trial15 and the ProtecT Trial.16 These provide important UK data on the diagnosis and treatment of non-aggressive PCaand pose two main questions:
The PROMIS Trial
Due to the PROMIS trial, NICE suggests guideline CG175 will in future recommend that mpMRI should be performed before TRUS biopsy17.
The ProtecT Trial
A number of our member organisations conduct Prostate Awareness Days at which they offer free PSA Tests to men. To find out when and where, click here.