Prostate cancer ‘test by request’ drives overdiagnosis

Most high-income countries, including the UK, do not have a national screening program for prostate cancer. Instead, men without symptoms can opt for a prostate-specific antigen (PSA) test after consulting with their doctor. However, experts argue that these shared decision policies have led to excessive rates of PSA testing, resulting in minimal benefits and clear medical harm with inequitable outcomes.

Andrew Vickers and an international group of colleagues propose that high-income countries should either adopt a comprehensive risk-based approach to PSA testing, aimed at reducing overdiagnosis and overtreatment, or discourage PSA testing by explicitly recommending against screening and implementing policies that make it difficult to obtain a test without specific symptoms.

Prostate cancer is the most common cancer in men and the third leading cause of cancer-related deaths in Europe. Nevertheless, it remains uncertain whether the benefits of current PSA screening practices outweigh the harms of overdiagnosis and overtreatment. Overdiagnosis occurs when low-risk tumors that would never cause symptoms or impact lifespan are detected and unnecessarily treated. In the UK alone, an estimated 10,000 men are overdiagnosed with prostate cancer each year, subjecting them to potential treatment side effects without deriving any benefits.

In light of this uncertainty, most high-income countries have embraced PSA testing based on shared decision making. However, the authors argue that relying on shared decision making has resulted in high rates of PSA testing, particularly among older men who are most susceptible to harm from screening and least likely to benefit. Moreover, the shared decision making approach perpetuates health inequities. For instance, in Canada and the US, PSA testing is less common among ethnic minorities, while in the UK and Switzerland, rates of testing are lower in economically deprived areas.

The authors propose implementing a comprehensive, risk-based early detection program for prostate cancer that not only manages testing but also biopsies and subsequent treatment. This approach could significantly reduce the harms associated with overdiagnosis and overtreatment resulting from PSA-based screening.

Alternatively, they suggest restricting PSA testing to men with symptoms, with some exceptions for a small number of high-risk individuals. However, they acknowledge that such policies are largely untested and require further research.

While they 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 practical outcome: high levels of PSA testing and medical harm, with minimal benefit and inequity, the authors state.

They assert that policymakers must choose between a comprehensive, risk-adapted approach designed to reduce overdiagnosis and overtreatment or restricting PSA testing to individuals referred to urologists due to symptoms. This decision should take into account the perspectives of patients and the public, as well as health economic considerations.

A linked feature questions whether the UK is truly ready to roll out a prostate cancer screening program. It highlights the presence of uncertainty, controversy, and the need for more evidence despite proponents and positive news coverage suggesting that a national program is “in the pipeline.”

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