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Prostate Cancer Screening

10 March 2015

BAUS Response to the UK NSC consultation on prostate cancer screening

National Screening Committee

The UK National Screening Committee (NSC) does not recommend screening men for prostate cancer. This policy was recently reviewed as part of the UK NSC's regular review cycle of all policies. The review process ran between March 2009 and December 2010. Full details are available by clicking here.

Prostate cancer screening is a complex issue. Two studies have recently been published which partly clarify the matter.

  • The PLCO trial failed to show a benefit for additional screening in an already heavily-screened population. It is likely that this so-called "contamination" of the control arm markedly reduced the power of the study, hence few conclusions can be drawn.
  • The ERSPC study demonstrates a 20% survival benefit surprisingly early in follow-up. However, this is at the cost of considerable over-treatment and, hence, significant side-effects in a group of men, most of who would not die from prostate cancer.
  • A third more recent study from the Göteborg group, published in Lancet Oncology, had longer follow-up, an earlier onset for screening and a slightly lower PSA threshold for biopsy. This study showed clearly that PSA testing saves lives from prostate cancer 1,2.The number needed to screen, and the number needed to treat were lower. Importantly, about a third of men with low-risk prostate cancer stayed on monitoring programmes, demonstrating that early diagnosis does not necessarily translate into "over-treatment".

The consultation assumes that practice has not changed since the first two studies were initiated. That is not the case, partly as a result of the NICE guideline on prostate cancer; an increasing number of men with low risk cancer are managed initially by active surveillance rather than radical therapy. Hence, the number of patients at risk of over-treatment and, therefore, of side-effects is lower in 2010 than the consultation suggests.

Overall, the evidence for screening is not yet sufficient to recommend it as a national program. However, that decision is much more finely balanced than the consultation would suggest. In addition, BAUS remains extremely concerned by data from the prostate charities which show that a significant number of men requesting PSA testing are refused the test by their GP.

The impact of the important Göteborg study was not considered by the panel and it is clear that, with longer follow-up, the mortality benefit and risk of over-treatment will change, hence an early review of this may be required.

In our view, these studies further support the idea that men should be aware prostate cancer can be diagnosed earlier by PSA testing and biopsy, and that this can save lives. Men should be able to request and receive prompt PSA testing and subsequent management.

References

1. Mortality results from the Göteborg randomised population-based prostate-cancer screening trial
Hugosson J, Carlsson S, Aus G, Bergdahl S, Khatami A, Lodding P, et al.
Lancet Oncol (2010), 11, 725-732

2. PSA testing for prostate cancer improves survival - but can we do better?
Neal DE
Lancet Oncol (2010), 11, 702-703

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