Weighing up the risks and benefits of prostate cancer screening | Prostate cancer

It is understandable that patients suffering from a late diagnosis of prostate cancer or families who have lost loved ones are demanding that something be done (Letters of December 5). However, I respect the recommendation of the UK National Screening Committee not to screen most men using the prostate specific antigen (PSA) test.

The committee’s job was to weigh the pros and cons of any test available for routine screening. The PSA test, as the first step in diagnosing cancer, results in false negatives and a significant number of false positives, meaning it has both low sensitivity and low specificity, making it a poor screening marker. PSA screening has been performed in the United States; According to various estimates, over three decades, more than a million patients have received treatment (e.g. surgery or radiotherapy) that they did not need.

Randomized trials are considered the gold standard in modern medicine. Approximations from the European Randomized Study of Prostate Cancer Screening estimate that PSA-based screening prevents approximately 1.3 prostate cancer deaths per 1,000 men screened over 13 years. This illustrates the problem of overdiagnosis of low-volume, low-risk cancers that would cause no harm to patients. In addition to a huge psychological burden for patients, any treatment may prove futile and lead to possible lifelong side effects (such as incontinence and erectile dysfunction).

As difficult as it may seem, we should not rely on PSA tests for routine screening. We must redouble our efforts to identify screening markers with high sensitivity and specificity, and accelerate research into the treatment of this terrible disease.
Aamir Ahmed
London

I deeply sympathize with your letter writer, Pat Sharpe, regarding the loss of her husband. However, as a retired consultant physician, I have always refused PSA testing. There is a naive belief that early detection and treatment improves outcomes. This is true for most cancers, but unfortunately this is not the case for prostate cancer. The best study I know of (Hamdy et al, New England Journal of Medicine, 2023) clearly shows that mortality outcomes are essentially the same whether patients are assigned to radical surgery, radiation therapy, or simple observation. Few patients die, whatever the group, and active treatment has no influence on this phenomenon.

However, radical treatment leads to frequent and horrible side effects. Screening is only of interest if there is effective treatment. This is not the case for prostate cancer.
Dr. Graham Simpson
Melbourne, Australia

Pat Sharpe’s letter resonates powerfully with my wife and me. I had always understood that PSA tests were worth little more than nothing. However, a year ago I had to have routine blood tests and decided to ask the nurse to include a PSA test because of an interview I had heard on the radio that morning. I was 62 years old, with no symptoms or reason to get tested.

I’m so glad I asked. I had a high PSA level (6.4) and was quickly diagnosed with high-risk, high-volume prostate cancer; luckily it was still contained.

I had a prostatectomy, which has its own consequences, but my wife and I can live with those. If I had continued in my ignorance, I wonder how many more Christmases I could have enjoyed.
Adrian Bell
Gosport, Hampshire

I first showed a (slightly) elevated PSA level about 20 years ago, during an annual check-up. The consultant I was referred to explained that I could have a biopsy but that this carried a risk of erectile dysfunction and/or impotence. So, valuing my continence and my sex life, I refused. This resulted in a gradual but steady increase in PSA over the following years. Eventually, I had a multiparametric MRI (mpMRI) and a number of other non-invasive tests, and was informed that the likelihood of me having cancer was very low.

As I understand it, mpMRI is a much more accurate predictor than PSA. Why is it not used in routine screening? Men who, like me, do not want to undergo a painful and potentially damaging biopsy might be much more likely to undergo a painless and safe mpMRI.
David Gollancz
London