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Towards Prostate Cancer Screening

Chris Booth, a member of our Clinical Advisory Board, reports on the outcomes of our Conference theme of "Prostate Cancer: To Screen or Not to Screen":

Over 47,000 UK men are diagnosed with prostate cancer (PCa) every year and nearly 12,000 die from it, a greater death rate now than for breast cancer.  Aside from the unpleasantness of death from PCa and its huge cost to the NHS, there is a clear inequity in the lack of provision and laissez faire attitude to our commonest male cancer, now killing a man every 45 minutes and with the UK death rate continuing to rise.

The UK Government’s health strategy is to promote prevention and early diagnosis, but without up to date guidance, the situation around prostate cancer screening in the UK remains as confused as ever for both men and GPs alike.  Whilst a veritable flood of “advances” in PCa diagnostics and clinical practice are reported every week, Public Health England and the National Screening Committee remain silent on PCa screening or repeat the outdated mantra that the “harms” of screening outweigh the benefits.

The Annual Conference of The National Federation of Prostate Cancer Support Groups (Tackle Prostate Cancer) in Birmingham on 13th June 2019 dealt directly with this problem under the Conference Title “Prostate Cancer:  To Screen or Not to Screen”.  A series of talks from organisations performing screening, an epidemiologist providing up-to-date information on the results of international PSA-based screening programmes, an expert GP and leading PCa charities (Box 1) provided a comprehensive, fact-based overview from which clear conclusions were drawn.  It should be emphasised that these conclusions are based on hard facts, not mere opinions.

World-renowned epidemiologist Professor Monique Roobol-Bouts from Erasmus University, Rotterdam presented compelling evidence from long-term screening programmes demonstrating 50% falls in PCa mortality.  She also showed how programmes can be constructed to target men at high risk whilst minimising testing for men at low risk, thus reducing to 100 the number of men needed to be screened to save one life.  From this the economic advantage of screening becomes clear.  This strategy has been adopted by the European Urological Association and was presented on 22/1/19 to the European Parliament as a recommendation to establish national PCa screening programmes.

In stark contrast Essex GP Dr Ann Williams’ presentation illustrated the problems facing GPs when a man asks for a PSA test (see Box 2).  It is clear that GPs would be unable to meet the standards required to provide a PCa screening programme, especially within the constraints of 10-minute appointments.

Conclusion
At the Tackle Prostate Cancer conference, a series of presentations dealt with all the current issues surrounding PSA and PCa screening. (Box 2).  Following this a coherent plan emerged to deal with the problem, key to which is a consensus that further screening “research” is unnecessary as the benefits of screening now massively outweigh the harms. For the reasons cited in Box 3, the UK should implement the introduction of a PSA-based screening programme as a national public priority.

Box 1  Participating Organisations

CHAPS Men’s Health Charity
Graham Fulford Charitable Trust
Orchid Male Cancer Charity
PCaSO
PROSTaid
Prostate Cancer Research Centre
Prostate Cancer UK
35 Prostate Cancer Patient Support Groups

Box 2     Perceived Problems with PSA-based PCa Screening 

  • PSA is not PCa specific
  • PSA may be negative when PCa is present
  • PSA may be positive when PCa is not present
  • Access to PSA testing is inconsistent
  • PCRMP* does not provide clear guidance on PSA use
  • GP knowledge of PCRMP and counselling is inconsistent
  • Interpretation of PSA results is inconsistent
  • PSA cannot differentiate between aggressive and non-aggressive  PCa
  • GPs receive insufficient urological training in general and PCa training in particular
  • GPs have insufficient time within a 10-minute consultation to counsel men adequately on PSA screening
  • GPs have not been updated on the benefits of PSA screening
  • GPs continue to receive outdated information on the “harms” of PSA screening
  • Screening for common cancers in the UK is organised centrally, unlike for  PCa

 *PCRMP:  Prostate Cancer Risk Management Programme

Box 3      Towards Prostate Cancer Screening

  • PSA remains for the foreseeable future the only viable front-line screening test.
  • PSA-based PCa screening programmes from Europe and North America are consistently showing a 50% or more reduction in PCa mortality.
  • The “harm” of over-diagnosis has been largely addressed by use of risk profiling, second line markers and mpMRI prior to any decision on biopsy.
  • The “harm” of over-treatment has been addressed by the introduction and safety of Active Surveillance for low risk PCa.  The current UK over-treatment rate is at least as low as 4%. (5th National Prostate Cancer Audit)
  • There are good screening models available for implementation; we do not have to reinvent the wheel.
  • GPs do not have the training, knowledge, structure or time to implement a screening programme.
  • A screening programme must be centrally organised and run
  • A new “low tec” workforce based on the voluntary sector and current laboratories with specialist urological input is capable of running a PCa screening programme.
  • A risk-based screening programme ensures the right men are tested at the right frequency and over the right periods of time.
  • A risk-based programme ensures costs are minimised and numbers needed to screen to save a life are now reduced to a figure lower than all other cancer screening programmes.
  • The current costs of long-term chemotherapy for advanced disease by far outweigh the costs of a screening service.