Incomplete portrayal of the value of PSA screening
Dear Editor,
While we acknowledge the importance of evidence-based policymaking, it is crucial to address this incomplete portrayal of the value of PSA-based screening and the significant harm such a narrative poses. The debate is more nuanced, and existing evidence highlights significant mortality reductions, especially for targeted screening among high-risk groups (with a family history of cancer, Black ethnicity, or under social deprivation). The recent Lancet Commission on Prostate Cancer emphasises the need for expansion of testing in high-risk groups.
The European Randomized Study of Screening for Prostate Cancer (ERSPC) and the Göteborg randomized screening trials substantiate the benefits of PSA testing and its impact on mortality. The ERSPC, involving 182,000 men aged 55-67, demonstrated a 20% reduction in prostate cancer-specific mortality over 16 years of follow-up. Similarly, the Göteborg trial reported a 35% reduction in mortality over 18 years.
Moreover, PSA testing has been shown to prevent one death for every 293 men screened. This compares favourably to breast cancer screening, which prevents one death per 337 women aged 60-69 and one per 1339 women aged 50-59, as well as bowel cancer screening, which prevents one death per 1173 individuals using faecal occult blood tests or one per 489 individuals through flexible sigmoidoscopy. These figures demonstrate that prostate cancer screening is as justifiable—and arguably more efficient—than these well-established programmes.
Arguments about overdiagnosis and overtreatment largely rely on outdated data that fails to account for modern techniques currently used for diagnosis, treatment decisions and monitoring. Multi-parametric MRI (mpMRI), now standard in the diagnostic pathway, allows for effective risk stratification, reducing unnecessary biopsies by over 25% and identifying over 90% of clinically significant cancers. The development of the transperineal prostate biopsy has reduced infection rates over the transrectal biopsy and improved diagnostic accuracy, especially when coupled with MRI data. These advancements address the historical concerns: many more patients with clinically insignificant cancers are spared a biopsy, and if they do undergo a biopsy, they are not overtreated. Meanwhile, timely treatment of life-threatening cases is ensured.
Moreover, the UK is a global leader in this area. Approximately 90% of small prostate cancers with a low risk of recurrence after treatment are managed with active surveillance (AS), a strategy now endorsed by the NICE that includes regular monitoring with PSA testing, mpMRI scans, and infrequent biopsies, and that ensures radical treatment is reserved for cancers with a potential to cause harm. Through AS overtreatment is minimised while maintaining excellent outcomes that set an international benchmark for balanced, evidence-based care.
While health policy must remain evidence-driven, dismissal of public engagement risks neglecting the inequalities in awareness and access to life-saving interventions. Advocacy efforts, when paired with transparent information, empower men to make informed health decisions.
It might be over a decade before the Transform study demonstrates significance of novel screening approaches using MRI to screen targeted men. At present the NHS struggles to meet demands on MRI imaging in patients with established disease let alone screen men who may be normal healthy. Hence an expanded early diagnosis programme will have resource implications. Again, the Lancet Commission points to possible solutions for this, for example with skill mix adjustments, use of artificial intelligence and streamlined rapid MRI sequences. Early treatment is more cost effective than therapy for metastatic disease, the potential economic benefits of an early diagnosis programme give additional impetus to move to such a development.
Prostate cancer screening has reached a pivotal moment. By integrating diagnostic and treatment advancements with targeted screening focused on high-risk groups there is a real opportunity to save many lives without causing undue levels of harm.
References
James et al Lancet 2024; 403: 1683–722 Published Online April 4, 2024 https://doi.org/10.1016/S0140-6736(24)00651-2
Hugosson J, Roobol MJ, Mansson M, et al. A 16-yr Follow-up of the European Randomized study of Screening for Prostate Cancer. Eur Urol 2019;76(1):43-51. doi: 10.1016/j.eururo.2019.02.009 [published Online First: 20190226]
Hugosson J, Godtman RA, Carlsson SV, et al. Eighteen-year follow-up of the Goteborg Randomized Population-based Prostate Cancer Screening Trial: effect of sociodemographic variables on participation, prostate cancer incidence and mortality. Scand J Urol 2018;52(1):27-37. doi: 10.1080/21681805.2017.1411392 [published Online First: 20171218]
Hugosson J, Carlsson S, Aus G, et al. Mortality results from the Goteborg randomised population-based prostate-cancer screening trial. Lancet Oncol2010;11(8):725-32. doi: 10.1016/S1470-2045(10)70146-7 [published Online First: 20100702]
Nelson HD, Tyne K, Naik A, , et al. Screening for breast cancer: an update for the U.S. Preventive Services Task Force. Ann Intern Med 2009; 151: 727–37
Towler B, Irwig L, Glasziou P, et al. A systematic review of the effects of screening for colorectal cancer using the faecal occult blood test, hemoccult. BMJ 1998; 317: 559–65.
Atkin WS, Edwards R, Kralj-Hans I, et al. Once-only flexible sigmoidoscopy screening in prevention of colorectal cancer: a multicentre randomised controlled trial. Lancet 2010; 375: 1624–33
Ahmed HU, El-Shater Bosaily A, Brown LC, et al. Diagnostic accuracy of multi-parametric MRI and TRUS biopsy in prostate cancer (PROMIS): a paired validating confirmatory study. Lancet 2017;389(10071):815-22. doi: 10.1016/S0140-6736(16)32401-1 [published Online First: 20170120]
Lopez JF, Campbell A, Omer A, et al. Local anaesthetic transperineal (LATP) prostate biopsy using a probe-mounted transperineal access system: a multicentre prospective outcome analysis. BJU Int 2021;128(3):311-18. doi: 10.1111/bju.15337 [published Online First: 20210412]
National Prostate Cancer Audit. NPCA State of the Nation Report. Published January 2024. Available from: https://www.npca.org.uk/wp-content/uploads/2024/02/REF433_NPCA-SotN-Repo... accessed 3 December 2024 https://www.nice.org.uk/guidance/ng131/chapter/Recommendations#localised...
National Institute for Health and Care Research. A randomised controlled trial to assess screening for prostate cancer compared to current standard of care. Available from: https://fundingawards.nihr.ac.uk/award/NIHR166607 accessed 2 December 2024.
James et al Lancet 2024; 403: 1683–722 Published Online April 4, 2024 https://doi.org/10.1016/S0140-6736(24)00651-2
Prostate Cancer Research. Socio-economic Impact of Prostate Cancer Screening. November 14 2024. Available from: https://www.prostate-cancer-research.org.uk/wp-content/uploads/2024/11/P... accessed 4 December 2024.
Competing interests:
No competing interests
12 December 2024
Stephen Langley
Professor of Urology, Professional Director of Cancer Services, Royal Surrey County Hospital, Co-Chairman Surrey & Sussex Cancer Alliance for Urology
Professor Nicholas James, Prostate and Bladder Cancer Research Team Leader, Deputy Dean (Clinical Studies), Institute of Cancer Research, and NIHR Senior Investigator.
Rapid Response:
Incomplete portrayal of the value of PSA screening
Dear Editor,
While we acknowledge the importance of evidence-based policymaking, it is crucial to address this incomplete portrayal of the value of PSA-based screening and the significant harm such a narrative poses. The debate is more nuanced, and existing evidence highlights significant mortality reductions, especially for targeted screening among high-risk groups (with a family history of cancer, Black ethnicity, or under social deprivation). The recent Lancet Commission on Prostate Cancer emphasises the need for expansion of testing in high-risk groups.
The European Randomized Study of Screening for Prostate Cancer (ERSPC) and the Göteborg randomized screening trials substantiate the benefits of PSA testing and its impact on mortality. The ERSPC, involving 182,000 men aged 55-67, demonstrated a 20% reduction in prostate cancer-specific mortality over 16 years of follow-up. Similarly, the Göteborg trial reported a 35% reduction in mortality over 18 years.
Moreover, PSA testing has been shown to prevent one death for every 293 men screened. This compares favourably to breast cancer screening, which prevents one death per 337 women aged 60-69 and one per 1339 women aged 50-59, as well as bowel cancer screening, which prevents one death per 1173 individuals using faecal occult blood tests or one per 489 individuals through flexible sigmoidoscopy. These figures demonstrate that prostate cancer screening is as justifiable—and arguably more efficient—than these well-established programmes.
Arguments about overdiagnosis and overtreatment largely rely on outdated data that fails to account for modern techniques currently used for diagnosis, treatment decisions and monitoring. Multi-parametric MRI (mpMRI), now standard in the diagnostic pathway, allows for effective risk stratification, reducing unnecessary biopsies by over 25% and identifying over 90% of clinically significant cancers. The development of the transperineal prostate biopsy has reduced infection rates over the transrectal biopsy and improved diagnostic accuracy, especially when coupled with MRI data. These advancements address the historical concerns: many more patients with clinically insignificant cancers are spared a biopsy, and if they do undergo a biopsy, they are not overtreated. Meanwhile, timely treatment of life-threatening cases is ensured.
Moreover, the UK is a global leader in this area. Approximately 90% of small prostate cancers with a low risk of recurrence after treatment are managed with active surveillance (AS), a strategy now endorsed by the NICE that includes regular monitoring with PSA testing, mpMRI scans, and infrequent biopsies, and that ensures radical treatment is reserved for cancers with a potential to cause harm. Through AS overtreatment is minimised while maintaining excellent outcomes that set an international benchmark for balanced, evidence-based care.
While health policy must remain evidence-driven, dismissal of public engagement risks neglecting the inequalities in awareness and access to life-saving interventions. Advocacy efforts, when paired with transparent information, empower men to make informed health decisions.
It might be over a decade before the Transform study demonstrates significance of novel screening approaches using MRI to screen targeted men. At present the NHS struggles to meet demands on MRI imaging in patients with established disease let alone screen men who may be normal healthy. Hence an expanded early diagnosis programme will have resource implications. Again, the Lancet Commission points to possible solutions for this, for example with skill mix adjustments, use of artificial intelligence and streamlined rapid MRI sequences. Early treatment is more cost effective than therapy for metastatic disease, the potential economic benefits of an early diagnosis programme give additional impetus to move to such a development.
Prostate cancer screening has reached a pivotal moment. By integrating diagnostic and treatment advancements with targeted screening focused on high-risk groups there is a real opportunity to save many lives without causing undue levels of harm.
References
James et al Lancet 2024; 403: 1683–722 Published Online April 4, 2024 https://doi.org/10.1016/S0140-6736(24)00651-2
Hugosson J, Roobol MJ, Mansson M, et al. A 16-yr Follow-up of the European Randomized study of Screening for Prostate Cancer. Eur Urol 2019;76(1):43-51. doi: 10.1016/j.eururo.2019.02.009 [published Online First: 20190226]
Hugosson J, Godtman RA, Carlsson SV, et al. Eighteen-year follow-up of the Goteborg Randomized Population-based Prostate Cancer Screening Trial: effect of sociodemographic variables on participation, prostate cancer incidence and mortality. Scand J Urol 2018;52(1):27-37. doi: 10.1080/21681805.2017.1411392 [published Online First: 20171218]
Hugosson J, Carlsson S, Aus G, et al. Mortality results from the Goteborg randomised population-based prostate-cancer screening trial. Lancet Oncol2010;11(8):725-32. doi: 10.1016/S1470-2045(10)70146-7 [published Online First: 20100702]
Nelson HD, Tyne K, Naik A, , et al. Screening for breast cancer: an update for the U.S. Preventive Services Task Force. Ann Intern Med 2009; 151: 727–37
Towler B, Irwig L, Glasziou P, et al. A systematic review of the effects of screening for colorectal cancer using the faecal occult blood test, hemoccult. BMJ 1998; 317: 559–65.
Atkin WS, Edwards R, Kralj-Hans I, et al. Once-only flexible sigmoidoscopy screening in prevention of colorectal cancer: a multicentre randomised controlled trial. Lancet 2010; 375: 1624–33
Ahmed HU, El-Shater Bosaily A, Brown LC, et al. Diagnostic accuracy of multi-parametric MRI and TRUS biopsy in prostate cancer (PROMIS): a paired validating confirmatory study. Lancet 2017;389(10071):815-22. doi: 10.1016/S0140-6736(16)32401-1 [published Online First: 20170120]
Lopez JF, Campbell A, Omer A, et al. Local anaesthetic transperineal (LATP) prostate biopsy using a probe-mounted transperineal access system: a multicentre prospective outcome analysis. BJU Int 2021;128(3):311-18. doi: 10.1111/bju.15337 [published Online First: 20210412]
National Prostate Cancer Audit. NPCA State of the Nation Report. Published January 2024. Available from: https://www.npca.org.uk/wp-content/uploads/2024/02/REF433_NPCA-SotN-Repo... accessed 3 December 2024
https://www.nice.org.uk/guidance/ng131/chapter/Recommendations#localised...
National Institute for Health and Care Research. A randomised controlled trial to assess screening for prostate cancer compared to current standard of care. Available from: https://fundingawards.nihr.ac.uk/award/NIHR166607 accessed 2 December 2024.
James et al Lancet 2024; 403: 1683–722 Published Online April 4, 2024 https://doi.org/10.1016/S0140-6736(24)00651-2
Prostate Cancer Research. Socio-economic Impact of Prostate Cancer Screening. November 14 2024. Available from: https://www.prostate-cancer-research.org.uk/wp-content/uploads/2024/11/P... accessed 4 December 2024.
Competing interests: No competing interests