Routine testing for prostate cancer is not recommended for most men because the benefit is small and uncertain and there are clear harms, say a panel of international experts in The BMJ today.
But they acknowledge that some men, such as those with a family history of prostate cancer, may be more likely to consider screening and, for these men, discussions about possible harms and benefits with their doctor is essential.
Their advice is based on the latest evidence and is part of The BMJ‘s ‘Rapid Recommendations’ initiative – to produce rapid and trustworthy guidance based on new evidence to help doctors make better decisions with their patients.
The prostate specific antigen (PSA) test is the only widely used test currently available to screen for prostate cancer. It is used in many countries, but remains controversial because it has increased the number of healthy men diagnosed with and treated unnecessarily for harmless tumours.
So an international panel, made up of clinicians, men at risk of prostate cancer, and research methodologists, carried out a detailed analysis of the latest evidence using the GRADE approach (a system used to assess the quality of evidence).
Based on a review (more than 700,000 men in clinical trials), which found that if screening reduces prostate cancer deaths at all, the effect is very small, the panel advises against offering routine PSA screening and says most men will decline screening because of the small and uncertain benefits and the clear harms.
Clinicians need not feel obligated to systematically raise the issue with all their patients, and should engage in shared decision making for those considering screening.
However, men at higher risk of prostate cancer death (for example, those with a family history of prostate cancer or of African descent) may be more likely to choose PSA screening after discussion of potential benefits and harms of testing with their doctor, authors concluded.
This view is supported in a linked editorial by Professor Martin Roland at the University of Cambridge and colleagues.
Both the panel and the editorialists welcome the UK government’s commitment to invest in prostate cancer research, and point to recent advances and active surveillance “which have the potential to reduce the harms of testing.”
In the meantime, they say conversations with patients requesting a PSA test “should explore their reasons for requesting a test, and include evidence based discussions about possible harms and benefits of PSA testing, informed by the patient’s ethnicity and family history.”