Informed choice approaches lead to high rates of unsystematic PSA testing, especially among those who are least likely to benefit and most likely to suffer harm, argue Andrew Vickers and colleagues.
Current policies on early detection of prostate cancer generate overdiagnosis and inequity with minimal benefit
Prostate cancer screening with prostate-specific antigen (PSA) remains highly controversial because it is unclear whether the benefits of reduced prostate cancer mortality outweigh the harms of overdiagnosis and overtreatment . Given this uncertainty, most high-income countries have chosen not to implement a national prostate cancer screening program, but allow men to obtain a PSA test after a conversation with their doctor.
Countries that have adopted screening policies based on shared decision making have seen high rates of PSA testing, particularly among men aged 70 and older, who are particularly prone to overdiagnosis but do not benefit from screening . This is one reason why opportunistic screening results in only a small reduction in cancer-specific mortality. Additionally, relying on shared decision-making to guide PSA testing has led to unequal distribution, with higher rates of PSA testing among wealthier and more educated people.
In 2022, the European Union recommended that organized screening programs be extended to prostate cancer. We argue that high-income countries should implement a comprehensive risk-based approach to PSA testing, one that is designed to reduce overdiagnosis and overtreatment , or discourage PSA testing. through a clear recommendation against screening, along with policies that make it difficult to obtain a test without defined urological indications.
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Most high-income countries, including the UK, do not have a national prostate cancer screening programme, instead allowing men without symptoms to have a prostate-specific antigen (PSA) test if they wish, after talking to your doctor. But experts writing in The BMJ argue that these shared decision policies have led to high rates of PSA testing and clear medical harms, with minimal benefit and inequity.
Andrew Vickers and an international group of colleagues argue that high-income countries should implement a comprehensive risk-based approach to PSA testing, designed to reduce overdiagnosis and overtreatment , or discourage PSA testing through a recommendation clear against screening, along with policies that make it difficult to get a test without specific symptoms . Prostate cancer is the most common cancer in men and the third leading cause of cancer death in men in Europe.
But it remains unclear whether the benefits of PSA testing, as currently practiced, outweigh the harms of overdiagnosis and overtreatment , when low-risk tumors that would never cause symptoms or shorten life are unnecessarily detected and treated. In the UK, for example, it is estimated that around 10,000 men are overdiagnosed with prostate cancer each year, exposing them to potential side effects from treatment without receiving any benefit. Given this uncertainty, almost all high-income countries have opted for PSA testing based on shared decision-making.
But the authors argue that relying on shared decision-making to guide PSA testing has led to high rates of PSA testing, particularly in older men, who are more likely to be harmed by screening and less likely to benefit. . The shared decision-making approach also reflects and reproduces health inequities. For example, in Canada and the US, PSA testing is less common in people from ethnic minorities, while in the UK and Switzerland, PSA testing rates are lower in economically disadvantaged areas.
Instead, they say that implementing a comprehensive, risk-based early detection program for prostate cancer that carefully manages not only testing, but also biopsy and subsequent treatment, could substantially reduce the harms of overdiagnosis and overtreatment that have accompanied by PSA-based screening.
Alternatively, they suggest restricting PSA testing to men with symptoms, with possible exceptions for a small number of high-risk men, but acknowledge that such policies are largely untested and would require more research.
“Although we believe that early detection of prostate cancer should involve shared decision making, the current approach of determining testing through shared decision making has resulted in the worst possible practical outcome of high levels of PSA testing and medical harm.” , with minimal benefit and inequality. "they write.
“To make better use of PSA testing, policymakers should choose between a comprehensive, risk-adapted approach that is specifically designed to reduce overdiagnosis and overtreatment , or restrict PSA testing to people referred to urologists with symptoms.” ”, they explain. “That choice will have to take into account a broader perspective of the patient and the public, as well as the economic concerns of health,” they conclude.
Is the UK really ready to roll out prostate cancer screening? It describes how advocates and positive news coverage suggest that a national program is "in the works," but encounters uncertainty, controversy, and the need for more evidence.
