Prostate cancer is the most common type of cancer in men. Outcomes are better when diagnosed at an early stage, whereas a late stage presentations can be associated with bone metastases. A recent National Prostate Cancer Audit report has shown that the proportion of men diagnosed at a late stage is higher in the North East and Yorkshire than in other regions.
Cancer awareness campaigns are based on recognition of the early symptoms. For prostate cancer the symptoms include a difficulty in passing urine, urinary frequency, urinary urgency, and erectile dysfunction, though these symptoms could also be due to benign conditions.
The problem of waiting for symptoms is that it leads to a large proportion of diagnoses at a stage when cure is no longer possible. Screening of asymptomatic individuals can be a better strategy to reduce cancer mortality, but only when there are valid screening methodologies.
In the UK currently there are screening programmes for three types of cancer: bowel, breast, and cervical cancer.
Prostate Cancer UK encourages all men to use their Risk checker: men aged 50 or above are identified as being at risk, as well as men aged 45-49 of black ethnicity or with a father/brother diagnosed with this condition. These men are encouraged to discuss with their GP and to consider the Prostate Specific Antigen (PSA) blood test as a possible screening test.
Professor Hashim Ahmed, a leading urologist, has recently urged all men meeting these criteria to consider PSA testing via their GP. GPs are less enthusiastic about this recommendation: they are already struggling with workload. How would they cope with large numbers of requests?
Proper screening programmes would need to be funded and to be done outside General Practice, as is the case for other cancer screening programmes.
Informed decision
Any decision to undertake screening testing should be an informed decision. In the past overdiagnosis and overtreatment of prostate cancer took place on such a large scale, that Blum and Scholz published a book in 2011 with a title (Invasion of the Prostate Snatchers) which paraphrased a 1956 science fiction horror film.
In 2012 the U.S. Preventive Services Task Force concluded that prostate cancer screening was not advisable because of uncertainty about the benefits and the risk of overtreatment.
The US position, though, partially changed in 2018 with the release of a nuanced statement, in which screening was presented as a possible individual choice that could be based on information about benefits and risks.
The evidence seems to have shifted further in favour of screening, particularly since a European study published in 2014 suggested that PSA screening could bring about a substantial reduction in prostate cancer mortality.
There have also been other game changers. A positive PSA test does no longer need to be always followed by prostatic biopsies, which are unpleasant and could cause side-effects. It is now possible to do a multi-parametric MRI first, thus reducing the number of men requiring biopsies.
Furthermore, it is now easier to identify low risk prostate cancers that are unlikely to ever cause any harm. In the past many of these cases were still treated with prostatectomy or radiotherapy, with little benefit and with unnecessary side-effects. Nowadays, low-risk cases would be just kept under active surveillance.
Early diagnosis is not just about reducing mortality: the more advanced the prostate cancer, the worse are the effects of treatment on quality of life. This is a sad reality for many prostate cancer patients.
The European Association of Urology (EAU) issued recommendations in 2021 urging the adoption of PSA testing screening followed by risk stratification and a multi-parametric MRI, before any biopsies are considered.
According to these guidelines screening might suit “well-informed men” with a life expectancy of more than 10-15 years. The Canadian Urological Association and the EU commission have made similar recommendations in 2022.
It might be just a matter of time before prostate cancer screening is more widely recommended. Currently men have a right to ask for screening but many are not even aware of this option, whilst GPs may struggle to support this approach. There is also a scarcity of websites with tailored information, which makes it difficult for men to be well-informed.
